Archive for the ‘Being a doctor’ Category

I take call and end up a patient.

April 23, 2017

At the end, it wasn’t a stroke

It was gone when I awoke

The symptoms were brief

Avoiding much grief

And I got to tell a crude joke.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 

Tuesday evening while on call, I got up to play Scrabble and I couldn’t make my right leg work. It didn’t feel heavy, numb or weak; it felt too light so that any effort to move it got exaggerated.   I sat down to do a neurologic exam on myself.  I found nothing other than my right leg ataxia.  I called Bethany from the next room, and told her the situation.  She helped me dress, and drove me to the ER.

The ARNP covering the ER did the same neuro exam I did, which wasn’t impressive until I demonstrated my gait.

She did all the right tests. The first EKG showed an old heart attack, which disappeared with proper lead placement.

She also found a heart murmur.  It hadn’t been present 5 years ago, but the PA at the VA found it a couple of months ago, and I called her attention to it.

My blood work had no surprises. She offered me the choice of staying in Clarinda or going into Council Bluffs, and I chose to go.  In terms of game theory, if something happened in the middle of the night, I wanted to be close enough for timely intervention.

In the process I had to make arrangements for someone else to take call.

I napped off and on for the ambulance ride, which almost got derailed twice by herds of deer. I bypassed the ER at Jennie Edmundson Hospital.  At 2:00 AM I had gotten settled, my IV had given me a couple of quarts, the second set of labs had come back and I’d had a good visit with the hospitalist ARNP.  Just before being tucked in, I offered the nurses a choice between a clean joke, a clean joke with a bad word, or a dirty joke.  They chose the last option, and I gave them the funniest crude joke in my large arsenal.

I don’t get to tell that joke as a physician, no matter how funny it is. But, as a patient, I can get away with it.  The punch line drew gales of laughter.

By then, motor control of my right leg was functioning at about 90%.

I slept for a couple of hours and had breakfast.

The neurologist arrived, and with economy of motion, did a thorough exam. He advised an aspirin a day and starting a low dose migraine medication.

The morning parade of tests started. By the time Bethany arrived I had done the basic neurologic exam six times and the symptoms had resolved except for the funny feeling inside my head.

I had an ultrasound of my neck, a consultation with the dietician (whom I amazed with my six pieces of fruit a day and my two ounces of salmon at breakfast), a consultation with the Occupational Therapist, and then the Piece de Resistance, the MRI. In between, I napped because I’d slept so lousy.

The hospital feeds its patients on the room service system; I ordered a lunch of soup, sandwich, and fruit, and within a half hour a young Guatemalan arrived with the food. We had a brief conversation in Spanish, I introduced my wife.

And we waited. The hospitalist came back, and went over the results.  Ultrasound demonstrated clean carotids (neck arteries).   The MRI didn’t show anything conclusive.  He also recommended an aspirin a day.

We waited for echocardiogram results. The hospital public address system announced a severe thunderstorm warning, and then a tornado watch in effect till 10PM.  The internet and the TV weather agreed that severe weather approached from the west.  At 4:45PM we decided to leave before the storm arrived, without the echocardiogram results.  We didn’t want to spend the night in the hospital, nor did we want to risk hitting deer on the way back to Clarinda.

Bethany drove. We enjoyed dramatic skies and listened to a Continuing Medical Education CD.  We ate at Clarinda’s premiere restaurant, J Bruner’s, ordering off the appetizer menu.

I returned to work the next day, the episode completely resolved, making it a transient ischemic attack (TIA), also call a reversible ischemic neurologic event (RIND).  Except I noticed my handwriting was much clearer.

I don’t think anyone else noticed.

Weekend call: nature abhors a vacuum

March 27, 2017

I took the weekend on call

I started with no patients at all

But I fixed that up quick

With the ill and the sick

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

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

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

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

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

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

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

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

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

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

It belonged to my grandfather. I drop his name.

 

 

 

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

March 26, 2017

Consider the places I’ve been

Then tell me, what does “call” mean?

For sometimes the word “call”

Means nothing at all

And sometimes it can make me turn green

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

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

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

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

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

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

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

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

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

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

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

I can tell you on Monday.

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

It’s not pernicious if the patient live

February 28, 2017

To test, I wouldn’t think twice

The abnormal I find ever so nice

And if that’s what they’ve got

I just treat with a shot

Still cheap at thirty times the price.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

 

About twenty years ago I stopped a neurologist in the hospital parking lot for a “curbside consult,” a long-standing tradition. These brief interactions transmit a lot of information.  In the days before the Internet, I realized I needed to know more about vitamin B12 deficiency than I could get from books or journals.

In medical school they taught us not to check B12 levels on anyone under 40. The characteristic findings on the blood smear, they said, with enlarged red cells, anemia, and white cells with too many nuclei, would show before anything neurologic; thus we shouldn’t run the expensive test if the person had a normal blood count.

Time has a way of slaughtering such dogma. I found myself in the middle of a diagnostic series of B12 deficiencies, the most recent at that time a 36-year-old with the classic blood findings. I modified my age criteria and, sure enough, found a very low B12 level, helping to account for symptoms of what otherwise looked like depression with clumsiness.

Before I collared the neurologist, I’d sat down to talk with the hematologist. In the course of 5 minutes I realized he didn’t know much more about the topic than I did.  Approaching the neurologist turned out well.

He said that anything under the lower limit of normal (has gone back and forth between 199 and 287 and has now held steady at 211) clearly shows a problem. Any B12 level over 400 can’t take the blame for a problem.  But the gray zone between 211 and 400 demands judgment.  Anyone with symptoms at or past age 65, he told me, should be treated.  At 35 cents a dose, you can’t justify the expense of further testing.

Since I started this blog in 2010, the price of vitamin B12 has gone from $.35 to $9.00 per dose, justifying further testing in the borderline area. Now when I have suspicions, I check levels of methylmalonic acid and homocysteine, two toxic byproducts that build up in the blood in the absence of adequate vitamin B12 and/or folic acid.

Just about anything neurologic, whether subjective or objective, prompts me to investigate. If someone complains of fatigue, numbness, weakness, depression, erectile dysfunction or trouble concentrating, I go looking.  And the same if the blood smear shows enlarged red cells (an increased MCV or mean corpuscular volume), or even a broadened range of red cell sizes (RDW, or red cell distribution width).

Last week I found 4 new cases of vitamin B12 deficiency on one morning, making me ecstatic to the point of silly. The next day I got elevated homocysteine levels  back on two other patients with borderline B12 levels.

We used to call vitamin B12 deficiency pernicious anemia because the patient always died, and I grew to love the diagnosis because as a frontline doctor I could save the patient’s life for 2 cents a day. Now it costs 30 cents a day.  It still makes me happy.

 

Giving bad news: it’s part of my job

February 27, 2017

I don’t wait till the end of the day

When there’s nought but bad words to say

I think that it’s best

To give one more night’s rest

Then suggest that it’s time to pray.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Part of my job is to think of the worst things I can think of, and a couple of times a day I will tell a patient that what they really want to do is to walk away from the hospital shaking their head and muttering that I’m nothing but a darned alarmist. I run a lot of tests.  Mostly I look for things I can do something about.  Sometimes I run studies so as to hand the specialist a patient with a clear-cut diagnosis, or, at the very least, the first level of testing completed.  But sometimes I’m looking for bad stuff, mostly to reassure patients.  I’d rather be happy than right.

Rarely, the battery of lab and x-ray comes back normal. Most of the abnormalities, however, come as no surprise.  People know the dangers of drugs, tobacco, alcohol and promiscuity.

Every once in a while, I have to give bad news. And, after all the labs and CAT scans and MRIs I’ve ordered in the last few days, I’m going to have to give some Very Bad News tomorrow.

The report came in at the end of the day. I don’t like to give bad news on a Friday or of an evening, when we have nothing to do but wait.  And I don’t let the nurse give the bad news, that’s my job.  I prefer to give the worst news face to face, but once in a while, for the expeditious good of the patient, I have to do so by phone.  .

People have suspicions when I start the testing, and for the most part when I sit down with them they already know the problem. So I ask, “What do you think the (blood test, CAT scan, biopsy, MRI) showed?”  Almost always they’ll say they don’t know, and I change the subject for about 5 minutes, and ask again.  The third or fourth time they come up with the diagnosis, and I confirm it, and I tell them as much as I can about what to expect.

I emphasize uncertainty when I find it, but I don’t hold out false hope. And if bad news involves a child, I come prepared for verbal abuse when the parents blame the messenger.

It’s part of my job.

 

 

 

Avoiding Windows 8 in the Morning.

January 5, 2017

I don’t want to install Windows 8

The function just isn’t that great

But before I begin

I must dodge once again

An update I try not to hate.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to 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.

My computer gets turned off at night, either by someone or by power outages. Come morning I face a powered-down machine, and I have to make a cold start.  This week, turning on the power button resulted in a 3 minutes wait and a demand to install Windows 8.

Our facility runs on Windows 7 Professional. I’ve worked with Windows 8 and found it balky and undependable, and, if I can believe what others say, the fault comes from the system.  Yesterday I undertook the same series of useless maneuvers three times before I could boot up Windows 7 Professional.

When I worked in Navajoland, my outlying clinic had power outages on average, 6 times a day, which effectively ruled out computerization. I had hoped to be the last computer illiterate member of the Yale Class of ’72, not buying my first machine till the late 80’s.

I’ve learned some things in the interim, including the universal Microsoft fix: turn it off, then turn it on. And if that doesn’t work, I know to call the Information Technology specialist.  Every health care institution now has one.

So after three unsuccessful laps around the wrong track, I walked out to the nurse’s station and asked for the IT number (the listed one got me Housekeeping, and however much I was tempted to ask if she had a trashcan large enough for my computer, I didn’t). One of the more computer-savvy nurses offered to have a look at it for me.  She punched the button that would have led to installation of Windows 8.

I gasped. My heart in my throat, I desperately reached for the power button, which, to my horror, didn’t turn the computer off.  Till I held it down and counted to 5.

A crowd gathered in my office, which eventually included the IT specialist. But by then, for unknown reasons, the Windows 7 Pro version booted up.  Luckily, I had witnesses.

The IT maven shook his head, took a seat, went to the control panel and did things that I didn’t understand.

Then, because the first patient of the day canceled, I chatted with him and the Nurse Practitioner that shares my office.

The NP had an independent practice for a couple of years before he came here. We volleyed horror stories of Epic, Cerner, and Centricity, but he had good things to say about PracticeFusion, the system he used.

I opined that every Electronic Medical Record system loses functionality with every update.  The Indian Health Service purchased the VA system and named it RPMS.  In the last 25 years, no one has tried to improve it.  Thus it still works.

Useless Recertification: it’s not just for doctors any more.

January 4, 2017

The process I do to maintain

Certification is too hard to explain

The Board, corrupted by powers,

Just wastes my hours

And puts dollars right down the drain.

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.

The physician community at large carries a grudge against Maintenance of Certification (MOC).

I suppose I agree with the general concept: that truth has a finite half-life, and that skills not continually updated deteriorate. Thus, during my radio career in 60s and 70s, my Third Class Radiotelephone Operator’s License from the FCC never needed updating, and, to the best of my knowledge, is still good.  Because I’ve not done broadcasting for almost 50 years, and because the nature of the job must have changed, it probably would do no good.

I knew a doc in Sioux City who got his Internal Medicine Board certification the last year it represented a lifetime ticket; after that all the internists had to take an exam every 10 years. He retired the same year I first went walkabout.

Family Practice, from its inception, embraced the concept of keeping current with an exam every 7 years.

The real world involves mission creep.  The American Board of Family Medicine (ABFM) has made the recertification process increasingly Byzantine.  A rep from that Board, at a Continuing Medical Education lecture said, in so many words, If it takes you more than 5 minutes to figure out what you need to do, call the Board.  There are well-trained people standing by to help you.

Too polite to express outrage, none of us said, “If your process has to be explained to people who take tests for a living, it’s too complicated.”

Eventually, when things got bad enough, the doctors rebelled. The American Board of Internal Medicine made the MOC process so complex, time-consuming, and expensive that a group of physicians broke away, formed their own Board, and went into competition.  The ABIM immediately apologized to its members, and backed off the requirements.  For a lot of docs who had hit an emotional tipping point, it was too little, too late.

The ABFM simplified things two years ago, but not enough to allow description in less than 500 words.

I talked to a patient involved in electric power generation (he gave me permission to write more than I have). At one time he held 8 professional certificates, but his work morphed so he let some tickets lapse one by one.  And none of them came cheap.

Bethany, a professional educator by training, is using her time here to complete her Maintenance of Certification. Which boils down to a lot of busy work, a needless expense, poorly worded tests with marginal validation, and has never demonstrated a benefit for anyone except those who charge her for the privilege.

But you could say the same thing of the recertification process for Family Practice.

Christmas 2016 on call

December 25, 2016

When it comes to Christmases all,

I’ll consistently take all the call

The 25th 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 25th 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

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.”

 

.

Vicodin found on a plane

December 18, 2016

You wouldn’t believe the stuff that I’ve found

On the road, the sidewalk, or ground

But it gave me a chill

When I picked up a pill

That was tan, not square, and not round

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.

During my med school years at Michigan State, the student paper carried a piece written by a runner. He kept a journal not only of his mileage, but of the money he found.  The piece pointed out that as time progressed and the value of the dollar decreased, he found more and more change.

I read that before I knew about complex systems, and while I took his point, now I realize that as time went on, he probably improved his money finding skills.

I find money, too, but I don’t run any more. And the amounts that I find progress with the years, so that what I found this summer, in the triple digits, stands as my all-time record.

I’ve also found gold and diamonds, but so rarely I can tell you the weather on those days.

Cycling or strolling, I find tools, as well. I pick them up because I usually end up needing them.  An acquaintance says I find things because I’m a hunter.

Getting onto the plane in Omaha, I found a pill on the floor. It didn’t require a lot of skill; the tan color didn’t match the blue carpet.  After we settled into our seats, I pulled out my smart phone and used the Epocrates pill ID app.  I entered the imprint and the shape and discovered I’d picked up a Vicodin HP, containing 300 mg of acetaminophen (also called Tylenol) and 10 mg of hydrocodone.

We have a nationwide epidemic of opioid addiction; the government has acknowledged that fact to the tune of billions of dollars of funding. Hydrocodone is one of the most popularly abused drugs.  Physicians, pushed by the Pain, the 5th vital sign initiative, and driven by patient-satisfaction survey-driven reimbursement, bear most of the responsibility for this epidemic.

I had to wonder about the person who lost the Vicodin. Was it the one it was prescribed for?  Did they want it medically or recreationally?  What did the patient say to the doctor to get the original prescription, and how many times did that particular pill get remarketed? What drama and irony went into the backstory?

I hope that the fact of finding that pill doesn’t signal the ease with which doctors prescribe such meds, but I suspect it represents the inflation of the supply side of the abusable drug market in this country.