Archive for the ‘Being a doctor’ Category

House call=the opposite of telemedicine

August 3, 2018

Let me tell you a story that’s tall

This gig that I’ve got is a ball!

For symptom description

Won’t suffice for prescription

And I get to make a house call!

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, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

Current sociologic forces will undoubtedly lead to telemedicine, which I feel compromises patient care.  Doctors don’t get into trouble by examining patients, they get into troubled by not examining patients. Thus when requests for prescriptions by phone arrived, I asked to see the patients.  For a multitude of legitimate reasons, two could not come in.  With a morning schedule of only 3 patients, I readily agreed to make house calls.

I love making house calls.  I get out of the clinic and the hospital and experience the patient’s context.  And I always get a few breaths of fresh air.  The patients always appreciate it.

As the morning wore on, the three patients on the schedule became 4, then 5; not a heavy clinc load, just a good, solid pace. And by the end of the morning, I had two seriously ill patients in the ER.

I run a lot of CT scans, and most of them come up normal. The majority of the rest come up abnormal but with abnormalities best ignored.  Half of those with abnormal scans showing problems needing treatment will, for one reason or another, agree to the treatment; about half will not.  And of those, few require treatment the same day.

But in fact I found myself talking to consultants in Sioux City, requesting they accept a transfer. Later, concerned about the growing cascade of delays, I asked how long the ambulance would take.

I don’t remember the last time a patient transfer via ambulance went smoothly or well.  I suppose the problem is inherent in the ER genre. When one patient left our ER in an ambulance and started down the road to Sioux City, I inhaled the relief, then moved on to the next patient.

I asked for help from the emedicine in Sioux Falls  Perhaps telemedicine, but with the all-important physical exam.  I texted a specialist friend for some advice. The patient stayed in the ER close to 3 hours, but got handled in town, without needing transfer.

Emergent patient care precluded lunch at the scheduled time, so at 1:00PM I bolted for gas station fried chicken 3 blocks away, and took it to go.

I tried and failed to relax while I ate, and, sure enough, just as I finished the last bite the nurse came to tell me about the first afternoon patient.

Still, I finished the 3 scheduled afternoon patients. When I looked at my electronic inbox, the last two names seemed vaguely familiar, and then I remembered my two house calls.

And on a fine summer day, the nurse and I set out with an administrator, who knew where we were going.

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Hot job, hot office

July 12, 2018

In my office I might take a seat

Depending on the degree of the heat

I’ll tell you, no fooling

I don’t get the cooling

And it’s hot enough to cook meat

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, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

Summer in Iowa brings sun, heat and humidity. The closer the temp gets to 85 degrees, the faster the corn grows; 2 degrees higher and the growth stops.  If the night fails to dip below 85 degrees the corn loses energy trying to keep cool.

You can find old farmsteads by their wood lots, 1-2 acre stands of trees that shaded a house from the sun in the summer, blocked the wind and snow in the winter, and provided fuel close to home.

Towering shade trees don’t fit in with 21st century American hospitals’ parking lots and helipads.  Air conditioning provides the necessary climate control.

(Last century, when I visited Cuba, I found hospitals, that depended on open architecture, breezeways, ventilation, and shade trees. But for obvious reasons, they don’t need parking lots.  And I visited in February.)

My clinic office has a great location on the west side of the building. Of all the rooms in the outpatient department, mine alone has no air conditioning.  More accurately, it has air conditioning but it doesn’t work.  On a good, hot, muggy day, I get some cool air in from the corridor in the morning, but as the afternoon wears on, my outside wall takes a beating from the sun, heats up, and radiates into the room.  And as the corn grows, I start to sweat.

Fans help by evaporative cooling. I got an aging tower fan that doesn’t work nearly as well as the desk fan Bethany bought at a hardware store on the square.  If I sit at my desk, the breeze on my face helps.  If anyone seeks to have a conversation with me after 3:00PM, I have to turn the fan so that they don’t suffer too much.  But then, I do.

When I worked in Barrow (now Utqiavik) in the winter of 2011, the hospital hadn’t had the heating updated since construction in 1964. Though the outside temp ran to -40, the clinic area stayed oven hot.  Entering a room, I opened by saying , “You can have privacy or you can have ventilation, but you can’t have both.  Door open or closed?”  And the patients always wanted the door open.  I could  stand by the window that no one ever closed, or I could even go outside without a coat.  Environmental services assured me they could not fix the system.  At the time, with the new hospital under construction, they weren’t about to try.

In New Mexico, my humble clinic’s windows always worked but the electricity didn’t. If the power went off, we opened the windows.  If the power went off in the winter, we kept on our coats.

The patient care here takes place in very comfortable surroundings, but I do my dictations and paperwork in the high 80’s.

Not surprisingly, I find myself spending more time with the patients, and trying to spend less time in my office.

A weekend call full of chest pain

July 9, 2018

This weekend I was hard pressed

And, as always I worried my best

The lilt in my song

Comes when I’m wrong

About the cause of pain in the chest.

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, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I took ER and hospital call this weekend.

The chaos that suffused my time came as no surprise, but the consistent theme of the people seeking my services, chest pain, did.

The area involved can be anywhere between the diaphragm and the jaw. The complaint doesn’t have to include pain; so often the person says, “It’s not a pain, really, more of a discomfort.”  And, sometimes the patient doesn’t feel discomfort at all, but shortness of breath, or nothing more than fatigue.

Of course I worry about the heart. If the body’s main pump runs out of blood carrying vital oxygen, it can’t pause to rest, and parts of the heart muscle die.

But I also have to consider the possibility of pulmonary embolism (blood clot in the lungs), pericarditis (inflammatory fluid around the heart), aortic aneurysm (where the aorta, the main artery coming from the heart falls apart), cancer, broken ribs, pleurisy (an inflammatory roughness of the smooth shiny membrane that lines the chest), or esophageal spasm (a cramp in the in the swallow tube).

By the end of the weekend, the nurses had gotten used to my routine: an aspirin, chewed, and a nitroglycerin pill slipped under the tongue, both while obtaining an electrocardiogram and getting blood drawn for a series of tests. Sometimes I asked for chest x-ray, sometimes a CT of the chest to rule out pulmonary embolism.

Sometimes the studies revealed the problem, sometimes not. I saw a good cross-section of diagnoses including the profoundly serious and the mundane.  I sent patients out by ambulance and by car, and I kept a couple in the hospital for observation.

(Everyone in town knows the helicopter came and went; for reasons of confidentiality I will neither confirm nor deny it had anything to do with a patient I attended.)

I took care of patients from the age of 13 to the age of 88. I enjoyed talking to two consultants I knew from my private practice and Community Health days.

But the highlights of the weekend had to do with me thinking of serious pathology and being wrong.

 

Once a patient, always a patient

July 8, 2018

The story came as a surprise,

Perfidy, adultery, and lies.

Misuse of narcotics

And antibiotics.

And names I wouldn’t surmise.

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, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I don’t have to know everything in the business; I have to know when I don’t know. I usually know who knows more than I do.

At my graduation from medical school, the speaker (so effective I still remember large portions of the address) told us to look in the mirror every morning and say, “I don’t know.” It took a few years but I got good at it.  Admitting ignorance does not bruise my medical ego anymore because reality has humbled me so often I don’t have one left.

Halfway through a laceration repair yesterday, I realized the wound went much deeper than I thought. I stopped immediately, doffed my surgical gloves, and called for help.

I put the call through a hospital operator who asked me to spell my name, which I did. Then I commented that she knew me but I hadn’t been around for a few years.  I could hear the smile spring back to her voice.

I had to re-introduce myself to the consultant, and, again, the telephone connection could not interfere with the smile.

Earlier in the day I needed to talk to a cardiologist regarding the proper time frame for a referral. I ran into that on-call doc at a dinner conference the week before.  He, too, smiled.

Still, medical communities qualify as living things: doctors come and doctors go. Change is inevitable.  I had a conversation this last week with a member of the Iowa Board of Medicine, and got access to some really juicy stories.  I cannot give the details here but I can give the moral lessons:  doctors should not have sexual relations with patients (and, once a patient, always a patient), they should not write narcotics prescriptions if they intend to use the narcotics for themselves, they should not misuse their position of power for financial gain.

None of those stories related to the local physicians, though some related to changes in the Sioux City medical community. Most came as complete surprises.

Most, but not all.

Looking for things I don’t want to find

July 1, 2018

Pessimism is my inspiration

When I’m testing for inflammation

Sometimes we’re stuck

With a run of bad luck

I’m hoping for no information.

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, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I make my living by thinking up worst case scenarios. As my knowledge and experience grows, I can dream up increasingly horrific things to rule out.

A lot of people, for example, just plain don’t feel good. I listen to the story, I take all the details seriously, I try to figure out the context, and then I go looking for diseases.  My favorites are the ones I can cure without specialist consultation, intrusive interventions, or expensive drugs.  I don’t like to find conditions that will last for the rest of the patient’s life, disrupting the plans of friends and family, misery that echoes down the generations.

Most disease, about 70%, comes to us directly from our choices: nicotine, alcohol, recreational drugs, overindulgence, and exercise avoidance.

But a sizeable portion of my work has to do with bad luck.

No matter what the source of the problem, my task is to make the patient better, and help the patient meet their goals.

But to get to that point I have to listen to the patient.

I listen a lot. I think pessimistically, and I run a lot of tests.

I use two particular assays, the C-reactive protein (CRP), and the erythrocyte sedimentation rate (ESR or sed rate) to make a major division in my lines of inquiry. Both seek to confirm or deny inflammation throughout the body, and two normals mean I can rule out a lot of illnesses. A high number in either parameter means I have to keep seeking till I find an answer, and, generally, an answer I don’t want to find.

Too many times this week I’ve looked at a lab sheet and used words unbecoming to a professional vocabulary.

At this point in my career, I shouldn’t take an abnormal lab test personally. I can either handle the patient’s treatment or I can find someone who knows more than me.

I look at the consequences of illness not just to the patient, but to the surrounding community. Every one of my patients exists in a context, and, just as the patient cannot be understood without understanding the context, the context cannot be understood without understanding the patient.

I shouldn’t take an abnormal lab test personally, but I do. Every patient is part of my context.

Hardware, software, and chairware

June 24, 2018

A problem is found, tell me where?

Is a problem that’s not the software

I said to IT

Perhaps it is me.

Is the answer to be found in the chair?

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, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

Eight years ago I took a course for doctors who want to be writers. Don’t use the word suddenly, they said, and never write, “All hell broke loose.”

I suppose all writing has rules, yet I haven’t figured out all the rules for effective blogging.

But I find myself enjoying this gig. A small hospital is an efficient hospital; one doesn’t waste a lot of steps.  Consider the context:  a functional Iowa town just big enough to have a hospital.  In two weeks I’ve dealt two marijuana users, and no drug seekers.  Every urine drug screen has come back clean.  Fewer than 10% of the patients smoke.

And I have time to spend with the patients. I listen attentively, I don’t interrupt.  I get to dictate my progress notes, and I can enter my hospital inpatient orders on paper.

I haven’t figured out how to use the Emergency Room EMR, not quite the same system as the inpatient program. I just couldn’t get it to turn on.

Today the Information Technology person asked me to show her the problem; I signed on and got a nice border on an otherwise blank screen.

“Is it the hardware?” I asked

She shook her head.

“The software?”

Headshake.

“The chairware?”

She looked at me, left eyebrow crowding the right.

“You know, the person in the chair?”

She burst out laughing, and told me she’d get back to me.

Despite cool, rainy weather, the clinic overheated. We got out the fans.  I sweated.  For the first time I realized that my large flat screen monitor produces a huge amount of heat.

The morning went at a reasonable pace. Online research, signing my dictations, reviewing labs.  Then at 11:00, suddenly, all hell broke loose.  The surgeon and the nephrologist each asked me for consultations.  The radiologist called from Orange City.  The neurologist called from Sioux City.  Two non-English speakers turned out to have a much more complicated clinical picture than we could have imagined.

I worked through lunch; the nurses and I did not get a chance to eat.

In the course of 4 hours I read 4 electrocardiograms, ordered 4 sets of labs and admitted 2 patients. I accommodated a walk-in.

I worked hard to replace my fluids lost to sweat.

And just as suddenly, things went quiet at 4:15PM. I finished with the two hospitalized patients at 5:00PM on the dot.  Food became my next priority.

 

Weekend call: lunch at the gas station or the country club?

June 20, 2018

You won’t believe what the ER nurse said

The patient came in on a wagon that’s red

Then later, for grub

We went down to the club

And on burgers and fries we were fed.

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, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I took call last Wednesday, worked the clinic 8 hours on Thursday, then took call again Friday, Saturday, and Sunday. Bethany came up for company on the weekend, by coincidence the town’s annual summer festival.

I had two patients in the hospital on Sunday, and after leisurely rounds we wondered about lunch. Neither the bar nor the Pizza Ranch would open before supper.  Which left two choices.

I asked Bethany, “Where would you rather go, the gas station or the country club?” We laughed, and decided on the country club.  I got out Google Maps, and checked the route.

Not wanting to be more than 20 minutes in case I got called back, we drove, but we could have walked the 5 blocks. The only customers in the middle of the afternoon, we ordered burgers and fries.  I ate with the relish and tension that lunch on Sunday call brings: savoring every bite knowing that I could be called away at any time.

Not a fancy lunch, but very tasty.

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In Emergency Department linguistic convention, the nurse will present the patient’s name, age, and gender, brief condition, and how that person arrived. Mostly I hear that the person “presented ambulatory via privately owned vehicle” or “presented on stretcher via ambulance.”  But people have also come in by boat, snow machine, bicycle, and ATV.  This weekend, for the first time, I cared for an adult patient who arrived on a Radio Flyer red wagon.

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In the last week I have had to do a lot of research. I can’t talk about the cases that inspired the research, nor whether related directly to a patient or not, but I learned a lot. Borrelia burdorferi causes Lyme disease, but the cork-screw shaped bacterium has a couple of cousins that can cause problems as well, and they can slip right past the standard Lyme disease test.  Provoked small rodent bites carry so little risk of rabies that the Iowa Hygienic Lab recommends neither treatment nor testing.  Twenty percent of the 20,0000 Americans bitten by rats last year developed rat bite fever, a disease easy to cure with penicillin.  To diagnose Legionnaire’s disease, run a test on the urine.

 

At 2%, am I Hispanic?

May 7, 2018

I thought hard when I made application

Do I come from a Hispanic Nation?

What can I say

If my DNA

Has two percent of donation?

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 back in Sioux City.  Any identifiable patient information has been included with permission.

I spent the day before my birthday filling out applications.

I devoted the morning to trying to get my work permit for British Columbia, so that I can return in October for 3 months. They wanted Employment Reference Letters, Labor Market Impact Assessment, Police Certificate, Employment Records (including pay stubs if possible), Passport copy, CV, Photo, Proof of Medical Examination, Contract, Proof that I meet job requirements, Family information (including the dates that my parents died), and an Application.  The CV, the employment reference letters, the employment records, and the Application overlap each other a great deal, but not completely.  By dint of hard work and previous information gathering, I got that task done before lunch.  But I still await an employers’ Reference Letter.

I took a nap, awakened refreshed, and started work on my Texas application. They wanted a lot of information, too, but I found little redundancy.   Demanding but reasonable, an online section wanted to know all my medical licenses that I had ever had, an understandable request.  This time, though, I didn’t have to fill in the start and stop dates and the license numbers.   But I had to complete several additional forms, having to do with my criminal record (arrested as an illegal pedestrian in 1971, a crime for which my memory exceeds the records of the Geary County, Kansas court), my malpractice record (named in a suit in 2003 and dropped 2 weeks before trial), and the one summer in medical school I didn’t attend classes. I found my work record for the last 5 years the hardest:  I worked 16 different venues as a locum tenens since 2013.

I wrestled with the race questions. My DNA analysis listed 5 European groups, with 4% Western Asian.  These days I try to put down as accurate a racial picture as I can, mostly because I think the idea is useless, but the application only gave me one choice.

I find the question of Hispanic origin equally difficult. How does a person answer that question if born in France and raised in Spain?  How about those indigenous peoples brought up in Spanish-speaking countries?  At what linguistic age does one qualify as Hispanic for the rest of their lives?  How many generations in an English-speaking country does it take to disqualify a person?  What about a person with 4 each Mexican and Norwegian great-grandparents?

And what about me, with 2% of my DNA coming from the Iberian Peninsula, and fluent to the point comedy in Spanish?

 

Where FedEx doesn’t go

April 17, 2018

My summer plans just fell through

There’s a thing or two I should do

It takes hours and ages

To fill out the pages

To serve at a clinic that’s new.

 

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, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

My original summer plans fell through but another opportunity arose, slightly closer to home. If all works right, I’ll take 24 hour call Wednesdays, with clinic on Thursday and Friday.  I would face a 38 hour work week, perilously close to the 40 hour norm.

For me, every work place change involves applications and credentialing. I worked on the packet, and put together 59 pages with 2 passport pictures I just happened to have.  While I could receive the forms electronically, the hospital wants what is now called a “wet copy:” the actual signed forms rather than scanned/emailed or faxed.

FedEx gets as far as Prince George. Using the Canadian Postal interface slows down mail to the US by weeks, and, from experience, sending things Express across the border involves a time frame that could be paired with the word Pony.

Purolator courier service, however, does a lot of business here. While they don’t have an office in town, they do have a driver.

The hospital has an account. With my Monday free as a reward for my weekend on call, I stopped in to the front office to inquire about Purolator.  Come back at 1:00PM, they told me, when we expect the pick up.

I walked to the mall and found an adequate manila envelope. I stuffed and addressed it and walked back over to the hospital at 11:00AM to find the Purolator van parked in front and the agent doing business in the parking lot.  When she finished delivering a C.O.D. package, I approached her with my packet.  She knew exactly what to do, but had run out of international labels in her van.  She had other stops to make, and asked how she could contact me.  I gave her my business card, and we agreed to meet in the hotel lobby in an hour.

She arrived on time, to the minute. Her consummate professionalism did not get in the way of her Canadian small-town friendliness and sense of humor.  I don’t think she expected me to have weighed the envelope (320 grams) nor to have called and found out the charge ($53.28CD).  Neither did the hotel front desk staffers who watched the transaction.

Everyone knows everyone here. I answered questions about why the package would go to Texas if the job were in Iowa.  I found out I don’t have to have my own Purolator account to send packages.

 

Weekend call: propranolol, Mounties, x-rays, Dave Brubeck, and geographic confusion

April 16, 2018

Geography knowledge is rare

And even those doctors who care

Have recommendations

That get emendations

With exclamations of “WHERE??!!”

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, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

Another weekend on call has passed. The heaviest day was Saturday; I attended 13 patients.  For the most part people came in a steady stream, yet I got breaks for lunch and supper.  With no regrets, I took every opportunity to nap.

I saw 4 Workman’s Compensation cases and 3 others from a motor vehicle crash. I don’t know why, but  I stand to benefit from laws governing reimbursement these two classes of injuries.  They represent the only two Canadian system areas lacking crystal-clear transparency.

My broad background helps me connect with a wide variety of patients. I relied on my short musical career to help one patient.  In the ‘60’s the Dave Brubeck Quartet’s artistry enchanted me into relentless listening of the ground-breaking album, Time Out.  I advised the patient to check two cuts on YouTube, Take Five and Unsquare Dance, examples of drum solos in difficult, unconventional rhythms (5/4 and 7/4) taken to artistic extremes.

I used my 7 years’ experience attending Adult Children of Alcoholics meetings to help another person. I pointed out that, just as perfect people rarely come to see me, perfect people rarely choose to become doctors.

I dealt with patients with neurologic, respiratory, infectious, psychiatric, blood, eye, gut, skin, and bone problems. I ordered and interpreted 3 electrocardiograms (all normal) and two x-rays (both abnormal). Four people had viral illnesses, expected to resolve with no treatment.   I ran 2 urine drug screens, results from one but not the other had surprises.

I sent one patient by ambulance to Prince George.

I called the Mounties once.

I ordered two CT scans for the upcoming week, fairly confident that one will come back normal and concerned that one might not.

I sought consultation from a Vancouver specialist who gave me a series of recommendations. After I hung up I called back.  She hadn’t realized the geography involved.  Just as well.  The patient (rationally, I felt) refused those measures.

I prescribed propranolol twice. With the blood pressure indication eclipsed by better drugs in the same class, it still has a lot of off-label uses: migraines, ADHD, stage fright, performance anxiety, premature ejaculation, rapid heart rate, tremor, and buck fever.  It stands as the first-line treatment for over-active thyroid.

I drove rather than walked the kilometer to the hospital. Temperatures have stayed close to freezing, with daytime thaws since I arrived, and frost coated the car windows after sunset.  This car rental didn’t include a scraper so I used a movie rewards card.