Archive for the ‘Becoming a Doctor’ Category

On marijuana, wages, and education

November 4, 2018

Here’s what to learn from the sages

Education is not just about wages

Your life it makes richer

For the depth of the picture

And it keeps your mind out of cages.

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, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Medical school starts with 2 years of classroom study, with little actual patient care except classes in interviewing and physical exam. Third year brings the cataclysmic change to clinical work: one month you sit in lectures and try to absorb as much as you can, and the next month you deal with people who bleed, vomit, cry, and sometimes die.

My medical school, based in East Lansing, sends 80% of the medical students to smaller communities for those crucial two clinical years. I went to Saginaw.

At the time, the automobile industry dominated the town. Up till then I had always lived either in big cities (not my favorite) or college towns.  Saginaw changed my context radically; I ran into a lot of blue-collar workers on a daily basis.  I had left my bubble.

One of my classmates, having grown up in Michigan, remarked that one of his high school classmates started working in an automotive plant at age 18, and a doctor would have to work till age 45 or 50 to match lifetime earnings.

I recall a millwright on the internal medicine service who made as much money as the attending physician, and worked much better hours.

Fast forward 42 years, and Bethany and I have landed in a different mill town.

Bethany substitute teaches. She found the elementary students polite to the extreme.

But she has concerns about many of the middle and high school students, concerns she shares with the administration. A lot of students don’t engage in class because as soon as they turn 18 they can start high-paying mill jobs.

My grandfather had a talk with me before I went off to college for the first time. A man so wise that even as a truculent 18-year-old I recognized his wisdom, he said, “You don’t get an education to earn more money.  You get an education because an educated man leads a richer life because he understands what he sees.”

Few people have a grandfather like that, and fewer still come from a cultural background that values learning for the sake of learning.

Of the 18 patients I attended on Friday, while the season’s first heavy, wet snow hushed the town, 14 abuse marijuana, using it multiple times daily. Of those, 12 have high-paying factory jobs, and of those, 10 have chaotic homes.

I don’t know where to look for causality, to the weed, the wages, or elsewhere.

But I do not think making marijuana legal will do anything positive to engage the students in school.

 

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High School Reunion 3: the Beatles Suite, no Scotch or cigars

June 19, 2018

The supper we passed bite by bite

As the party went into the night

The smoke was too risky

To go out for some whiskey

And some of us still have to write.

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After some part-time work in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I am taking a break from Sioux City for my 50th High School reunion.  Any identifiable patient information has been included with permission.

One of my classmates had the terrific generosity to buy a crowd of 25 a very nice meal at a landmark Denver restaurant, the Brown Palace. The talk ran to careers and retirements.

Most of my classmates remembered my days with the Navajo and the Indian Health Service. More than half find themselves in some phase of retirement.

I announced my intention to keep going till 2035 as much from sincerity as for the shock value.

After dinner our host showed us his room, the hotel’s Beatles Suite, where the Fab 4 stayed during their Red Rocks performance in 1964. We talked about music.

Jimi Hendricks, Vanilla Fudge and Soft Machine played at the venue in 1969 with an opening band called Eire Apparent. The number of my classmates attending astounded me, equally that I had seen none of them there.

I would assert, and many would agree, that popular music reached a zenith between 1964 and 1975. Well trained musicians broke with musical conventions, tweaking formulae, and writing poetry that may yet stand the test of time.

I can’t overstate the importance of music to my generation. In the days before digital recording devices, when music came pressed onto vinyl or magnetized onto tape, a person’s record collection and how they cared for it served as a personality thumbprint as well as a financial barometer.

Two of us had been in the Preps, the school’s instrumental group who played Big Band numbers. One had his own rock band, playing significant gigs in Denver and Boulder even before he was 18.  I still play sax, and I mentioned my time playing professionally in Barrow, Alaska in 2010.

Another classmate, a former Glee Club member, still composes and sings.

Our host suggested Scotch and cigars; I declined as my distaste for smoke far outweighs my appreciation of fine distilled spirits.

I caught a ride back to my sister’s house with a chum I’d first met in September 1963 when we started into 7th grade; I collided with him again during my pre-med years at University of Colorado at Denver.

We both write. I mentioned my 9 novels.  I have nothing published and haven’t had an agent since the first one.

I told him I blog, and he asked, “How often do you feed the dragon?”

I like a turn of phrase so good it gets a lot of play without being trite, and even better for application outside of its usual ball park.

While I work, I said, 4 or 5 posts a week. His face showed both shock and amazement.

Not everyone writes. Those of us who write do so because we have to, not because we think we’ll get paid.

High School Reunion 7: Epilogue

June 6, 2018

I wouldn’t go back if I could

To practice the way that I should

Would the music I write

Bring the world light?

As a doc, I’m doing more good.

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I took a break from Sioux City for my 50th High School reunion.  Any identifiable patient information has been included with permission.

 

I left Denver for Boston on a red-eye flight, with a layover about lunchtime in Indianapolis.

I struck up a conversation with a waiter who served me in an airport restaurant. He saw my noise-cancelling headphones and called them “really nice.”

They were an anniversary gift from my wife, I said. To the delight of the children present, I showed off my really nice, spiffy yoyo, also an anniversary gift from my wife.  I didn’t mention the really nice bicycle repair stand she’d bought me for our 10th anniversary.

He asked how Iowa differs from Indiana, and farming popped into my mind first, so I talked about how Iowa might have good ground, but Indiana has better. Then I had to explain that I work as a doctor, not as a farmer.

Because he found himself working on a holiday (Memorial Day), I asked if he were a student.

Working two jobs to save money to further his schooling he found himself in an educational hiatus.

He composes music, and he wants to change the world for the better thereby.

I told him I started my first undergraduate career as a Theory and Composition major. I told the truth, that I hadn’t wanted to do the disciplined work to develop my meager talent, and that I didn’t fit into the dominantly gay subculture of the college music scene.  But I didn’t tell the whole truth, that I had gone to Yale, with one of the best music programs in the world.

I have a high school friend who still qualifies as a musician, I said, and when we play our tunes from the ‘60s I express amazement that I wrote stuff that good.

But I again made the observation that I have done a lot more good as a doctor than I ever would have done as a composer.

I want to tell him that the chances of him actually making enough to pay for housing and food and transportation by playing and composing with artistic integrity come close to the odds of winning the lottery; he faces fierce competition from hoards of those determined to follow their passion, and competition drives down the price.

But I don’t. If he succeeds he can revel in it, and if he doesn’t, his dreams will die a hard death soon enough.  .

 

High School Reunion 6: into the Denver Country Club for the very first time.

June 5, 2018

Of our class we missed 28

There were three who had met their fate

And as for the rest

I just think it’s best

To say they’ve got too much on their plate.

 

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I took a break from Sioux City for my 50th High School reunion.  Any identifiable patient information has been included with permission.

Our reunion Class Dinner took place at the Denver Country Club.

I called Denver home from 1956 to 1979. I have returned at least once a year since, and I had never set foot in the Denver Country Club. I don’t know when the facility dropped its ethnic exclusions for financial reasons, but I make a habit of avoiding places where I’m not welcomed.

Out of a class of 43, 15 of us showed for at least part of the activities. Which leaves 28 who didn’t come.

One of my classmates, 25 years ago, while soliciting funds and participation on behalf of the school, made the observation that we were a very alienated class. I could not disagree.

Some suffered more than others.

Statistically, the class would have had between 2 and 4 gays, who would not dare have come out in such a virulently, violently homophobic environment.

A Native American, from the Arikara nation, attended a couple of years. We all remembered him as extremely smart and very quiet.  He and I ran half-mile and mile together.  In retrospect, I shudder at the quantity of racism showered on him.

We had a Hispanic, also extremely quiet and smart, who arranged with a teacher to do a self-paced calculus unit while the rest of us worked on pre-calculus. While we valued him as a friend, we showed no cultural sensitivity.

One came from the Thai Royal Family, and we understood his absence.

I had to consider that half the class didn’t pass the senior English final, and weren’t allowed to graduate with the class. I could understand them carrying a grudge though I hope that they don’t suffer from doing so.

The class list marked 3 as deceased.

All in all, not a bad turnout.

Three classmates and a significant other shut down the party at the prematurely septuagenarian hour of 9:30. As we exited, we noted that the DCC would have excluded us in 1968.

We never felt discrimination from our classmates.

I never thought of myself as one of the cool kids, though.  And then I thought better.  I had no enemies in my class.  I must have been one of the cool kids.

High School Reunion 5: The Colorado Academy Gun Club and the “Bill Jones” incident

June 3, 2018

A math instructor named Bill.

The headmaster noticed his skill.

He didn’t stay

Past the very first day

For he went about armed, for the thrill

 

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I took a break from Sioux City for my 50th High School reunion.  Any identifiable patient information has been included with permission.

I graduated from Colorado Academy in 1968, having started 6th grade there in 1962.  In my high school years, we had a number of student organizations I wanted to explore but never did, among them the Gun Club and the Archery Club.

The Gun Club emphasized shotguns. They met after lunch to shoot clay pigeons, and reloaded shells in the Biology Lab.  The biology teacher overseeing the operation we fondly referred to as Bwana because he loved to hunt.

The Archery Club also met after lunch; in the days before compound bows and bow sights they made their own cedar shaft arrows.

Boarding students, during season, could check out their shotguns first thing in the morning, and go down to the pond to hunt ducks and geese. The dining hall staff would prepare any birds harvested.

We never had problems with violence or misuse of firearms. Nor did we have a single accidental shooting, though we suffered through a disturbing number of other accidental deaths.

The school required we take Hunter’s Safety in 9th grade as part of the biology curriculum.  The textbook, BSCS Green Edition, emphasized ecology.  Rachel Carson’s Silent Spring was required reading.

From the beginning we learned to respect firearms as tools, with proper rules of use.

I do not know when the Colorado Academy Gun Club ceased to exist.

When we returned for reunion, we carried awareness of the Columbine and Parkland tragedies, and we asked the Alumni liaison about plans for an active shooter. The school added a “welcome center” (really, a guard hut) shortly after Columbine, and two non-faculty staffers carry firearms.

Many years after I graduated, when Because the Rivets Will Scratch the Seats, a school history by John Sullivan, came out, I read with alarm about the “Bill Jones” incident.  The Headmaster had hired a new math teacher about 1962. On the first day of school, the instructor greeted the students normally at the bus.  In the classroom, he took out his .45 and laid it on the desk. Within hours the headmaster had the armed teacher in his office.  He separated the instructor from the firearm and eventually succeeded in getting him back to his psychiatric hospital.

The incident puts a different spin on the move to arm teachers.

I never heard anything about “Bill Jones” during my primary and secondary education, nor had any of my classmates. They hadn’t read the book.

 

High School Reunion 4: oral history video

June 1, 2018

We made up a book, just a spoof

And the card was inserted, as proof

A system so swinal

Failed half on the final

And, fifty years later, there’s proof.

 

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I am taking a break from Sioux City for my 50th High School reunion.  Any identifiable patient information has been included with permission.

I arrived half an hour late for the oral history session video recording, ready to tell the truth, and as always, the truth contains some ugliness. I sat and listened, and after a moment glanced at a sheet of suggested questions.

The discussion, as I entered, ran to the subject of the hardest teachers; two names came up repeatedly.

One brilliant math teacher held the patent for the circular slide rule. (Few remember the slide rule, a computing device limited to 3 significant digits; making it circular rates as an act of pure genius.)

The other taught Senior English. He didn’t stop at the difference between metaphor and simile; he distinguished good from bad literature and taught how to read in depth.  Every week we read a book and reviewed it in addition to the class reading assignments (for example, Moby Dick).  To teach us to work under pressure, he would surprise us with a 3 page paper due the next day.

He had a fully subjective grading system and never gave A’s. A single misspelling, grammatical mistake, punctuation error or use of the verb “to be” would bring a decrement of a letter grade.

None of us could remember the single ambiguous question that failed so many on the final, so that half the students walked with the class but they didn’t graduate. A quarter attended summer school.  Even then, some didn’t pass.

Yet, for all that, many of us still write, and all of us read critically.

No one but me remembered an easy teacher, a man who taught music theory and composition with clear expectations and lots of praise.

I described the day Mr. Esbenshade announced he would speak no more English in Spanish class, and how I thereby learned to speak Spanish.

Another question asked about pranks. The Class of ’67 outdid us.  They sodded the English teacher’s room and wrote “Good literature can make you smell the grass” on the board.  They carried the Headmaster’s Bentley to the front steps and left it where it couldn’t roll.

But a group of my classmates, fed up with the weekly English assignment (read a book and review it), reviewed a non-existent book and had the audacity to make up and insert a card for the library’s card catalogue. They got away with it.

Discussions wandered from the original question. Most memories and vivid stories took place outside.  People rappelled off the dormitory roof; they hiked and biked and skied.

Once, the Mountain Rescue leader (who also taught shop and played viola) sent some of the students on a deer drive. Jumping from a tree onto the deer, dispatching it with nothing but a knife, he showed the students how to dress out the carcass and he fed them the meat.

The second to the last question asked if, knowing what we do now, would we choose to go to Colorado Academy for our education.

Nothing comes without a price, you can never get more out of something more than you put in. We all agreed we got an incomparable education.  So we talked about that question, but not one of us would answer it.

 

 

 

High School Reunion 2: Dinner at Denver’s Brown Palace

May 31, 2018

Of that high school I am a grad

The education we got wasn’t bad

When I met with my mates

Standing up straight

Recalling the times that we had.

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I am taking a break from Sioux City for my 50th High School reunion.  Any identifiable patient information has been included with permission.

I swaggered into Denver’s Brown Palace Hotel for a dinner with my high school classmates.

In 1968 I graduated from Colorado Academy, a school exceptional even in the world of private education. The brochures at the time touted it as half boarding and half day, meaning that 50% of the students lived on campus and the rest commuted.  It occupied a former military academy campus.  When I arrived in 1962 we still had stables and barracks and a few students wearing Army-style uniforms.

Imagine an all-boys school full of smart troublemakers from dysfunctional families with a startling proportion of gifted teachers.

Some of the boarding students lived close enough to ride the bus home on weekends.

The school day started with a half-hour assembly and the Lord’s Prayer, no matter what faith we had at home. After lunch a student could elect a number of activities including wood shop, band, Mountain Rescue, archery, glee club, and gun club.  After classes, policies required team sport participation 2 trimesters out of 3.

I took part in every stage production from 9th grade on.  I ate dinner with the boarders, and got a ride home from the drama teacher.  In many ways I qualified as day student and boarder and neither.

The homework ate every moment of spare time but gave us incomparable study habits. By comparison, Yale was a breeze.

While many bemoan current Political Correctness, I remember the blatant racist, sexist, homophobic climate of the Cold War years.

We got fantastic educations.

We learned critical thinking and healthy skepticism, two skills without which people fall prey to false news and propaganda.

In my clinical experience, auto-immune diseases, such as the anklylosing spondylitis that robbed me of a teenager’s swagger respond exquisitely to a person’s emotional health; the academic pressure compounded my chaotic home life’s stressors, which worsened my back pain.

Which, in turn, saved my life.

Seven years of well-documented back pain, along with a peculiar back x-ray, made me unfit for military service during the Viet Name war.

My proper diagnosis came in 1981; I started the miracle drug Enbrel (you’ve seen the commercials) in 2000. My spine straightened, and I walked with a fluidity I hadn’t felt since childhood.

The Onyx room at the Brown Palace held about 15 of my classmates, a few spouses, and one of our teachers. Some I knew immediately, for some I had to look at body language and listen to speech patterns before recognition came.

Despite my swagger, my classmates knew me.

 

 

 

 

High School Reunion 1: Siblings, sushi, and fractures

May 29, 2018

The cause might have what it takes

For the fractures that give rise to the aches

The stresses from running

Can be downright stunning

Bringing the ankles to breaks.

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I am taking a break from Sioux City for my 50th High School reunion.  Any identifiable patient information has been included with permission.

I grew up in Denver. I went to a private school with uncompromising academic standards, and I returned here for the 50th reunion of my high school class, 1968.

My family arrived in 1956, when the city had fewer than 500,000 inhabitants. As I grew, the city grew.  I remember when the population passed a million.  I stopped growing, the city didn’t, and suburban sprawl long ago devoured wheat fields and cattle ranches.

I left Denver the first time in 1968, bound for Yale. My vow to never return lasted almost 6 weeks.  I returned in 1972 to do my pre-medical education at University of Colorado at Denver.

At that time I thought the traffic just barely tolerable, and I resented how much time I spent getting from one point to another.

I lived in my mother’s basement then, and regarded that house as my permanent address till 1979, when I finished med school, and cleared out my belongings on my way to residency.

I came in a day early because I still have family and friends in the Denver area. My parents passed away years ago.  Two of my sisters, one of my brothers and his wife, a brother-in-law, two nephews and a niece still live here.

I retain a map sense of the city’s general layout. The major arteries have changed; Interstate 25, which we used to call the Valley Highway, runs 8 lanes through the city.  Santa Fe Drive, formerly the Santa Fe Trail, has entry and exit ramps.

I marveled at how much the air quality improved in the last 50 years, despite obscene traffic, and equally at courtesy of the drivers.

In the late afternoon my sister, her husband and I went to meet my brother, his wife, another sister with her boyfriend and two children for sushi. My niece fell and injured her wrist, necessitating a trip to Urgent Care and thus a change of restaurant.

Our family likes to gather, we go out of our way to do so, and this time my arrival served as the excuse.

My brother had just finished taking the Medical College Aptitude Test (MCAT), and he asked me what it was like when I took it in 1974. I could but remember one question, and that regarded Saladin and his place in the history of the Crusades.  I hadn’t known about him when I took the exam, but I looked him up afterwards.

The MCAT’s General Knowledge section, which contained that item, has since dropped out of the exam due to massive cultural bias. Medical schools still use the MCAT score and the premed GPA as inflexible cutoffs.

My sister and her children joined us while we munched edamame. My niece broke both bones of her right forearm just about the wrist; she came in with a sugar tong splint and a sling.  Towards the end of the meal her facial expression told us all that her ibuprofen had worn off.

I showed her how to put her wrist over her head. Within a minute a smile reigned and she went back to giggling.

I told her to use gravity as an ally whenever possible, as gravity inevitably pulls downhill the swelling that amplifies pain.

Soon the adults told broken bone stories.

At age 17 x-rays showed stress fractures of my lateral malleoli: breaks in my outside ankle bones sustained from compulsive running.

Normal teenagers don’t run so far or so hard that their bones break, and, perhaps, normal people don’t come back for their 50th reunions.

 

 

A friend’s death 5: leaving

March 17, 2018

With one exception, when I wrote about the death of my brother-in-law, I have opened these posts with a limerick.  Understandably, until now.

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

 

Paul, Bob’s son, and Paul’s wife, Cara, do some marvelous cooking with beautiful presentation, and made a wonderful breakfast.

I did a lot of cooking during the two years Bob and I lived under the same roof in the early 70’s. At the time, most considered cooking to be women’s work.  But I, like many in my generation, questioned pre-defined gender roles.

In later years cooking became a major part of our connection. The winter he lived in Minneapolis he visited most weekends.  Once, when my wife and children went visiting elsewhere, Bob and I thawed some wild ducks and prepared them according to Russ Chatham’s Great Duck Misunderstanding.  The end product was seared on the outside, rare in the middle and topped with a sauce to die for.

I recounted the story over breakfast.

But, mostly, we talked about Bob, his upbringing, and his life. We agreed he would have made an excellent internist, but taking premed courses at Yale discouraged a lot of would-be physicians.

(I did my premed at University of Colorado at Denver, a commuter college, after I finished at Yale. I don’t think I would have gotten adequate grades in physics, chemistry, and calculus if I had tried at an Ivy League institution.)

Bob had some trouble with the law, and never shared the details with his family. I revealed the secrets, which I won’t relate here.  At his sentencing, Bob shocked his lawyer by speaking out of turn, taking responsibility for the crime, and getting his co-defendant a much reduced sentence.  Bob got 60 days in a half-way house and a year’s probation; the other guy got 6 months’ probation.  But Bob figured things out on a moral basis, and took personal responsibility for his life.  Without doing a 12-step program, he did the 12 steps on his own, right down to living a day at a time.

The codefendant never reached Bob’s level of understanding, and, no matter what the death certificate says, went on to die of amorality.

After I’d finished the story I looked at the clock and knew I needed to leave.

As I merged into the eternally frenetic South California traffic, I turned the radio on, then turned it off to think about writing.

Bob and I shared an acquaintance with a real author, with dozens of books in print, who said that the people who write are those who have to write, a piece of wisdom that still rings true. I’m one of those who has to write.

When Bob wrote, he wrote well. His exposition came clear, articulate, and well-structured.  He lamented his inability to write fiction, but enjoyed my novels.  He served as an unfailingly accurate sounding board, his criticisms brought depth.

That resource is now gone.

Still, when I write, I write from the heart. This series, since Bob’s death, has been the hardest since I started my blog.

 

Croup treatment has and hasn’t changed

December 21, 2017

With a cough like the bark of a seal
And the kiddy so good doesn’t feel
There’s no way to avoid
A dose of steroid
Croup must be treated with zeal.


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. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.
I had cause to contemplate how things do and don’t change in medicine. Consider, for example, croup. If a virus swells a child’s narrow airway, a barking cough, much like a seal asking for a fish, follows. Death can ensue if the airway narrows to the point of closing, or if the child stops breathing out of exhaustion.
The pediatric ward in the hospital where I did my residency had two outdated features for treating croup when I arrived.
One consisted of a tiled room that could be filled with water vapor; a large cloud chamber that could sleep 8. During my tenure its only use was storage.
But the spacious balcony on the other side of the nurses’ station told a different story. It had sliding glass doors and space for 6 cribs. In a bad croup year, the nurses bundled the children up, to sleep with their faces uncovered in the cold, dry Wyoming air.
It worked for most of the kids, and I still recommend that strategy, saying, “Now if the spasm of croup doesn’t clear in 3 breaths you’re already headed to the ER.”
Treatments have come and gone and come back. Antibiotics, we found, did no good. Theophylline (a close cousin of caffeine, and found in pharmacologic amounts in chocolate) helped, but not much, and had a lot of side effects so has since been completely displaced by the albuterol (in Canada, salbutamol) updraft.
Every winter, during the peak croup season, I’d ask my pediatrician friends if we’d gotten anything new for croup, and every winter they’d shake their heads.
We used to use inhaled adrenaline (also called epinephrine). It has come and gone in five year cycles. A year and a half ago I thought for sure that I’d never use it again when I heard a study showed it did no better than inhaling saline (salt water).
We used steroids a lot and stopped for a while in the 90s, started again just before the millennium, and continue to this day. Controversy remains regarding dose, and method of administration.
But croup has changed. The really, really bad version, where the epiglottis (the flap valve between the airway and the swallow tube) swells has disappeared with modern immunizations for diphtheria and Hemophilus influenza. And with the decreasing smoking rates we don’t see nearly as much as we used to.
I had cause to research croup treatment recently, finding, to my surprise, that all my internet sources recommend inhaled epinephrine and steroids. Just like 1982.