Archive for the ‘Alaska Life’ Category

Winter Alaska Life: really cold and dark

November 12, 2017

Consider the price of the meat

What you get at the store can’t be beat

But up here, to be blunt,

The price of the hunt

Makes the comparison sweet

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

In the northern hemisphere, the sun sets later daily from June 21 till December 21, the Winter Solstice. At points on the Arctic Circle, the sun doesn’t rise at all that day.  The winter I worked Utkiagvik (then called Barrow) I arrived a week before dawn; if I had come early enough, I would have experienced night from November till January.  Here we have about 72 hours when the sun doesn’t show itself, and that won’t happen till after we leave.

When the sun sets, it will set in the south, not the west.

I find myself now so far west that I can watch the sunrise at lunch.

+*+*+*

For the most part ER mornings run slow, with late afternoon surges. I hit the cafeteria early, before noon and at 430PM.  Not only the aging eat so early; I did so in residency when I worked ERs in Wyoming.

I cover ER not out of passion for the genre but out of obligation as a team player. Still, the set up here has brought me no more than 9 patients per clinic day, and the ER has brought me no fewer than 10.  Thus ER here has brought me more professional satisfaction.

I would prefer shifts shorter than 12 hours.

+*+*+*

I love languages. The North Alaska Native Association (NANA) partnered with Rosetta Stone and in 2007 brought out two versions of Inupiaq, Coastal and Interior.  On previous Alaska trips I tried but failed to get the product.  This time, though, the local NANA office had the item for sale, and on a rare day off I tramped through a light snow and bought it.

But I couldn’t get the software to install. Yesterday, in another rare day off, I called RosettaStone.  It took 90 minutes to find out that the program can’t be used with my current software (Windows 7 Professional).  The phone rep cheerfully told me that I could add another language, and which language did I want to buy?  After 3 tries he still didn’t understand that, working with Inuit I wanted to speak their language.  He just thought I wanted to add to my inventory.

+*+*

The price of hunted meat, including license, travel, fuel, and ammunition, makes the end product unjustifiable from an economic perspective. Here, however, where food either comes by airplane or comes into the area of its own accord, pursuit of game animals and fish brings in the cheapest calories.  “Stew” in the lower 48 means the meat flavors the vegetables.  Here, with potatoes running $3/pound, one flavors the meat with the vegetables.

The town has 3 grocery stores, all of them expensive. One sells reindeer meat.  On my day off I bought a couple of pounds at breath-taking prices, and cooked up a stew.  Delicious, but it really needed 4 hours of simmering rather than the 2 ½ hours I gave it.

 

 

 

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This year’s first Arctic day seeing patients

October 22, 2017

The one forty-five didn’t show

Perhaps the wind and the snow

Made him think twice

About going out on the ice

Where a fall can be the stop of your 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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic. Any identifiable patient information has been included with permission.

I started in to seeing patients this morning after rounds. The first patient of the day would have presented more difficulties if I didn’t speak Spanish with considerable tolerance for dialectic variation.
I got a chance to write when my 1:45PM patient didn’t show.
In less than 72 hours the weather went from overcast and rainy to snowy, then clear. When snow falls, people become the unwilling slaves to Newton’s 3 laws: A body in motion remains in motion absent external force, a body at rest remains at rest absent external force, and for every action there is an equal and opposite reaction. Friction can conceal those laws from our consciousness, but put dry powder snow onto black ice, and people slip, slide and fall. And then they come to see me.
The real heart of a medical visit, though, lies in evaluating what the illness means to the patient. And each patient so far today arrived with unique circumstances with a fascinating back story.

Consider the overall Alaska picture.  Natives have seen tremendous change, and many have been engulfed by linguistic upheavals.  In the memory of people younger than me were the trips onto the winter sea ice, camping in igloos to hunt seal with harpoons, using dogs to find the holes in the ice where the seal come to breathe.  Most non-Natives moved here from somewhere else, and each one finds themselves in the middle of a personal odyssey.  Of the small number of non-Natives, born here, most have moved around, a lot.  Each move has its own tale of motivations, losses, and gains.

Those, like me, who keep coming back to the 49th state, have their own epics.  This time I’ve found two people I’ve worked with before in other places on the Alaska coast, and a third is soon to arrive.

New Year’s Day, walk on the beach

January 2, 2017

We went for a walk on the beach

To see what the ocean could teach

Then the tracks of mink

Made us question and think

As the eagles in cedars would screech.

 

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.

 

Being a couple of well-established party vegetables, we retired New Year’s Eve at 9:30, only to be awakened by fireworks at midnight. We could see most of them from the bedroom window.  Bethany opened the curtain, we put on our glasses and lay in bed, watching.   The display went on for a quarter-hour.  Bethany drifted off to sleep.

The sun rises late here, not till after 8:30. We went out for a walk on the beach with one of the pharmacists.   The island has diverse geology, and resistant rock outcroppings break up the strand.  Pacific flotsam dots the high-tide line; the most colorful parts I found were ropes, nets, and plastic containers.

We spotted an immature eagle soaring. We walked on the sand when we could, but mostly we slipped and slid over shingle, the pebbles and cobbles on their way to becoming sand.  We clambered over interesting layers of granite, layers turned vertical by unspeakable geologic forces.

People walk their dogs on the beach here, we expect to find canine and human tracks in the sand. But we also found a lot of lynx tracks, and we could read a dramatic story of a large cat stalking a very small deer, but the novel’s end got lost where the sand merged with the broken rock.

We heard the skittering, high-pitched call of an eagle in a towering cedar, but couldn’t spot him.

And we came across the distinctive, delicate marks that mink paws make in the sand. In one spot we found the shell of a sea anemone apparently retrieved from a tidal pool at low tide by a mink and consumed on the spot.

Then we found 3 drag trails, each paralleled on one side by mink tracks, each coming up from the jumble of stones and puddles of water and erratically but inevitably leading up the beach, past the high-tide line and into the rain forest and muskeg. We followed as best we could.  Though I track well for my age and demographics, I couldn’t follow the trail on the rock or on the spongy floor of the forest.  We wondered how many mink constituted the party, and what they had caught.

When we had gone as far as our aging knees, ankles, and backs would take us, we turned around. The wind died down, the sunshine warmed us and we unzipped our jackets.  Against an astounding blue sky we spotted eagle after eagle, gliding from the water into the trees.

 

First week back in Metlkatla

December 22, 2016

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.”

 

.

Underworked and overpaid

August 30, 2016

The setting in Alaska was pretty

Near eagles and bear’s there’s a city

With specialists plural

You can’t call it rural.

And it paid really well. What a pity.

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.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

I worked a week in a city in Alaska.

Alaska doesn’t have many cities, but it has more than one.

They put me up in a very nice hotel, walking distance from the workplace.

Medicare pays doctors very poorly in rural areas, so badly that a doctor cannot cover overhead if the practice includes too large a percentage of elderly. So a lot of private practitioners refuse to see new Medicare patients, and some will terminate care on the patient’s 65th birthday.

Massachusetts attacked the problem by making Medicare participation mandatory for licensure. The doctors responded by moving away.

(Canada’s system pays a premium to rural practices, but they still don’t have enough rural doctors.)

So in this particular city one of the larger institutions put together a clinic for the elderly to take the burden off the Emergency Rooms. Salaried physicians see Medicare patients; the clinic depends on grant monies to continue operation.  The model lacks sustainability.

But the docs still need vacations.

I confess I said yes to the job because of ego; I liked the idea that they would fly me to Alaska, and put me up, for a week’s work.  I had hoped to work for a week a month and get in some fishing before my return, and I would have, if paperwork hadn’t moved at a glacial pace and my wife hadn’t come down with a benign brain tumor.

So on a beautiful Monday morning, I got two interviews, a name tag, and a couple of pamphlets by way of orientation, and started to work in a large hospital complex.

My previous experience with their electronic medical record (EMR) system came in handy despite the major differences between versions.

With not much on the schedule, I sat down with the first patient and said, “Tell me about your problem.” I listened without interrupting till the word flow stopped, and said, “Tell me more.”  At the next long pause I asked, “What else?”

With never more than 7 patients on a days’ schedule, I could take a lot of time with each patient. I enjoyed listening to the Alaska pioneer stories.  One 72-year-old male patient gave me permission to write that he had biceps a 16-year-old would envy.

Most of the patients of both genders have hunted, many still hunt, and I enjoyed discussion of moose and caribou weapons.

I could access specialty services, including ER, quickly, but, as easy as it made my job, it didn’t fit with my conception of Alaska as the ultimate in rural experience.

And, for me, rural makes the adventure.

Of Red Tide and dead walrus

April 16, 2016

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.

March 23, 2016

When it came to the blackened entrée

I hardly knew what to say

The salmon’s the surf

But the moose is the turf

And the wind blew the high heat away

 

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. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Friday we drove out to a potluck at the house of one of the other docs. I brought an Asian salad, Bethany made bread.  Other treats included sweet potato casserole, Spam fried rice, Philippine corn nuts and peanuts and pork rinds, bean salad, potato salad.

While the temperatures this winter have hovered around freezing, the mercury started to plunge last week, into the single digits. The Bay froze over, and the wind picked up.

The host faced a culinary challenge: cooking outdoors when the wind chill sucked so much heat that he had to construct a windscreen.

The entrée consisted of the unique surf and turf of this area of Alaska: blackened moose and salmon. At the end of the party I asked for and received tips on the process of blackening.

Monday the snow fell and fell hard, and I had something I very rarely have, a slow day. I perused my email.  I did some online CME, but mostly I sat.  My tally for the entire day stayed in the single digits.

Today during rounds I heard a doctor referred to a patient as a “high liner.” Too much of an outlander to have heard the term, I waited till I cared for a commercial fisherman later in the day to ask, and I learned the term refers to the best commercial fishermen, the ones who consistently bring in large catches.

One of the first patients of the day came in with a neck lump. In short order I diagnosed a sebaceous cyst, a collection of cheesy, smelly material that happens when one of the skin oil glands gets plugged.  With an apparently open schedule, I agreed to cut it out right then.  We gathered the gear, I wiped the area with alcohol, prepped it with Betadine, and draped it with a sterile towel.  Then I couldn’t find it, nor could the patient, nor the resident.  David Copperfield could duplicate the trick, but I had to repeatedly plead that I had no idea what I’d done.

In the afternoon, a young patient arrived to follow up on a shoulder injury, and I very quickly found range of motion loss. In a culture such as this, where everyone hunts and fishes,  incapacity of a shoulder can have terrible consequences.  After the x-ray, while I awaited contact with the specialist, I used an osteopathic technique called muscle energy.  I brought the arm to the barrier, and using my own muscle power had the patient perform an isometric contraction away from the barrier for 5 seconds.  I instructed in a relaxing breath, got 10 degrees more of motion, and repeated the process.  Then I showed the patient how to do it without me.  That person left with better range of motion, and I finished the day euphoric from making two people better before they left.

They both gave permission to publish more information than I have.

 

Athabascan languages and radio traffic

March 11, 2016

Today’s limerick at the bottom.

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. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

I learned to speak Navajo in the early 1980’s in Canoncito, New Mexico. My teachers asserted ability I didn’t feel and made me speak for myself.  My first sentences stumbled at two words in length.  The language has 32,000 tenses and no regular verbs; I pretty much kept to the simplest of the present tenses.  I could make myself understood, and the people showed great generosity in their tolerance.  Despite my lack of grammar and vocabulary I had good pronunciation.  Sometimes my patients or the staffers would burst out laughing because, they said, “You sound just like a real person.”

Navajo language belongs to the Athabascan family. Those cultures call themselves Naa Dine (or something very close), meaning People.  The men practice mother-in-law avoidance.  Women run the society. They potlatch: every few years those who can throw a massive party for the purpose of redistribution of wealth.   Those peoples mostly call the North Pacific area home.  Anthropologists have a lot of interesting theories about why the Navajo and the closely related Apache live so far from other Dine.

The area of my current assignment includes several villages of Athabascan speakers who call themselves Denaina. Today I asked a Denaina speaker if the language were close to Navajo.  “We have a lot of the same words,” the person said, “but they mean different things.”  Struck by the universal truth of the statement, I laughed out loud and asked to use the quote in my blog.

***

The Alaska State Legislature is currently debating Bill #98 to regulate telemedicine. Docs out here in the wilderness have been doing telemedicine for decades under the old law, which demanded an examination before any prescription.  The remote hospitals trained Community Health Aides (CHAs) to do examinations and dialogue with doctors via radio.  Now with good telephones connections  and cell phones we still call talking with the CHAs “radio traffic.”  At this hospital, each physician has an ongoing relationship with a number of villages.  And every village has a clinic with a limited pharmacy.

The new law lacks consideration for good patient care and the reality of life in villages accessible only by air or by water. One of our docs went to Anchorage to testify against the bill, and I wrote him this limerick:

We work in places remote

You can to by plane or by boat

We rely on description

To make our prescription

Please, for this bill, do not vote.

 

Nobody in the audience laughed.

 

 

Referrals to Anchorage and Rembrance of Reye’s

March 6, 2016

We’re much further out than is rural

Logistics would make your hair curl

I don’t know the choice

But there’s burnout in voice

When I need to make a referral

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. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Medicine has always been a team sport, none of us alone is smarter than all of us put together. Our profession has always relied on specialists.

You can’t drive to where I work from anywhere but here. Nonetheless, 21st century American medicine requires referral to specialist from time to time.  They come here on regularly.  Ears, nose, throat (ENT), for example, flies in for a week every two months and has a packed schedule.  Cardiology comes four times a year.

We have a system for getting referrals down to Alaska Native Medical Center (ANMC), which starts with a simple call to a Case Manager, always a Registered Nurse (RN). All three RN nurse managers have a firm grasp of realities of Alaska life and the way inherent logistic problems color the provision of medical care.  Occasionally, the problem at hand demands a close time frame, which is when I have to speak doctor to doctor.

On two occasions so far I have made such calls. The neurosurgeon spoke from or past the brink of burn out; he would not yield to any attempts at cheeriness or optimism.  The cardiologist’s voice showed more resilience.

I remembered another Indian hospital, in another state, in another century. The adoloscent came in with intractable vomiting and personality change; I needed less than 5 minutes to make the diagnosis of Reye’s syndrome, a malady that disappeared when we got out the message not to give children aspirin. But we didn’t know the link then; we knew the liver turned to mush and the brain swelled and sometimes the child died, and we didn’t have much in the way of treatment.

After the first five minutes, I had to call the lab tech in, and midnight came and went while I awaited biochemical proof. Once I had the diagnosis solidly confirmed, I called the University medical center an hour away and started working my way up the hierarchical ladder.  I presented the case to the student, intern, and resident.  By the time I got to the chief resident at 3:00AM I could deliver the presentation in less than a minute, but my nerves had started to fray.

I could hear the chief resident’s heart break in the sigh and the pause. Clearly overworked and sleep deprived, he sounded cornered when he said, “Well, I guess you’ve got to send the patient down.”

I can look back on my own burnout and I can empathize with the other doctors, but I don’t have a solution when we cannot make enough doctors to staff the system without working most of them more than 60 hours a week.

The neurosurgeon probably works more.

Power outages and head lamps.

February 18, 2016

 Sometimes, when down falls the snow,

Out the power will go

But what I use instead

Is the light on my head

Which in my pocket I stow.

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. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

This winter, till now, has brought little snow to the area. Temperatures have consistently topped those at home in Iowa.

But today I trudged through fat, wet flakes the 250 yards to the hospital. Yesterday’s rounds lasted close to an hour, reviewing the significant cases that happened over the long weekend.  Today the presenting doc announced the expected death of an elder, and all action stopped for a moment.  The person’s passing will leave a void in everyone’s life.

Patient flow slowed to a trickle with enough snow to ruin driving but not nearly enough to make roads passable to snow machines.

At 10:00AM the lights flickered and went out. The laptops, running on batteries, glowed in the dark.  Then the emergency generator kicked in, and the fluorescent fixtures lit up again.  Business went on as usual.

With heavy, wet snow straining the electric wires, power went off and on the rest of the day. We kept working.

One patient gave a long, complicated, difficult to follow history, and if I’d had to hurry I would have gotten annoyed. But I didn’t, so I listened, and, after a while, I took notes.  The power flickered again, and I ordered some tests, the results of which showed serious pathology, bad enough I referred the patient to the ER and wondered whether or not the Medevac plane could fly in such snowy weather.

I took away a lesson I already knew: people get sick whether or not they can tell their story well.

A patient whom I’ve followed for more than a week came in after lunch. I asked one of the younger docs, with more surgical training, for help.  In the middle of the minor procedure, during the stitching, the lights went out and stayed out.

I carry a head lamp in the pocket of my white coat. When I first started private practice, LEDs had yet to revolutionize the flashlight industry, and head lamps stayed anchored to the wall.  A medical grade head lamp cost upwards of $200.  The one I have in my pocket cost $30 at Cabela’s, feels cheap to the touch, and provides better illumination than anything available in 1990.  I use it to examine mouths and other places where the sun doesn’t shine, to help during minor surgery, and to remove ear wax.  Today it helped finish the surgery.  Just as I cut the last suture, the lights came back on.

Then not much happened for the rest of the afternoon. I left outpatients early, and Bethany and I braved the roads to drive to the library.  I borrowed a couple of books.  If the power goes out, I’ll stay entertained.

Till my headlamp batteries go out.