Archive for the ‘Being a doctor’ Category

Remembrance Day, without cognitive drift

November 19, 2018

Consider the dragons you feed.

When it comes to the smoking of weed

Add up the expense.

It doesn’t make sense

But neither does booze, you’ll concede

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.

Canada celebrated Remembrance Day last week.

In elementary school we learned about Armistice Day, and few people now remember that WWI fighting stopped at the 11th minute of the 11th hour of the 11th day of the 11th month of 1918.

Armistice Day still exists, but the celebration has morphed. The US celebrates Veterans’ Day, and Canada has Remembrance Day.  The clinic and a lot of the town’s businesses closed.  I even bought a fake poppy and pinned it on my lab coat the Friday before.

The day after, I came back to work rested and refreshed. I had a fantastic morning.

Not a single patient that I attended before noon used marijuana. Perhaps some people can get high responsibly, but the people who get sick don’t know when they’ve had enough tobacco, alcohol, or cannabis.  And now that Canada has legalized weed, heavy hemp usage has become an increasing factor in anxiety, depression, insomnia, erectile dysfunction, testosterone deficiency (“low T”), falls, and accidents.  Poor short-term memory and impaired ability to deal with numbers makes history taking and patient education problematic.  So my morning went more easily.

If a patient’s story keeps changing in terms of concrete details such as numbers, dates, and times, the cognitive drift clues me in to probable intoxication.

Alcohol and tobacco, and increasingly marijuana, of course, give me job security. I had patients that morning with insight into their problems, taking steps to deal with their addictions.

Almost every patient with an addiction knows they have a problem before they walk through the clinic door. By the very definition, an addict continues an addiction despite negative consequences.  But few realize the financial costs.  So I added up the addictive costs for a patient and came to a total over $15,000.  (That approach failed when caring for a tobacco-chewing Inuk who spent less than $100/year on the habit.)

Every patient gets subjected to observational neurology. I look, I listen, I touch, and I smell.  The basic examination of the nervous system starts when the patient comes into the room.  The neurologists will tell you that watching a person walk and listening to them talk will get you through 90% of the diagnostic possibilities.  I used those skills last week to make a tentative diagnosis, and I look forward to seeing a patient improve.

 

 

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How to put 75% of the physicians out of a job

November 19, 2018

Perhaps genetic predilection

Could serve for behavior prediction

I’ll make a confession

Like those in my profession

I’m employed because of addictions.

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.

Addictive processes have commonalities. People lose count, they lose control, they fail at trying to set limits, the addiction takes priority over health and family, adverse consequences happen but the behavior continues and continues to demand more and more time as use escalates.

Not surprisingly, addictions account for a disproportionate part of my business.

Fewer than 15% of Canadians smoke, but smokers today make up 75% of my patients.

Most drinkers smoke and most smokers drink, and, not surprisingly, most marijuana users also use tobacco and alcohol.

Long ago I quit trying to get substance abusers to admit to a problem. Most of the time I can get them to tell me about the chaos that envelops them.  When we discuss alcohol, marijuana, or meth, they generally make light of the problem, and I ask, “How’s that working out for you?”

I do not contradict the people who say, “Just fine.”

But I frequently try to get the patient to talk about their goals. And then I ask, “How does $8,000 dollars going every year to tobacco, alcohol, and weed fit in with your plans?”

Those techniques I got from a program called Motivational Interviewing, and, thanks to the wonders of the Internet, it has become available to anyone with a computer. It allows a person to capitalize on someone else’s ambivalence.

I do not expect to see the impact of Motivational Interviewing immediately; doing locum tenens I rarely see the impact at all.

But last week over the course of 2 days, 6 of my patients declared intentions to get clean and sober. Three asked to be sent for counseling, and two have already started going to meetings.

Each one of them comes from a back story of betrayal and abuse, loaded with drama and irony and promises made and broken. If they keep on the path of recovery, they will discover that weaknesses can be strengths and strengths can be weaknesses, depending on application and timing.

I hope this trend continues and spreads. Doing away with addictions could potentially put ¾ of the doctors out of business.

I hope I live long enough to see it happen.

Suffering Call: it’s not just for doctors anymore.

November 18, 2018

This town has milling and mines

And power than runs down the lines

You might slip or fall

When you come off of call

Whether working with people or pines.

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.

Much has changed in medicine since I graduated medical school in 1979, but some things haven’t. Sick people want to get well and don’t want to see strangers.

Patients want three things from a doctor, in this order: availability, affability, and ability.

Doctors must offer services to those who need them in the middle of the night, thus my profession will always demand some sort of call scheme. My father, a cardiologist, expected to answer calls and take care of patients 24/7/365; he masked his disapproval when I revealed I regularly shared call with 4 other docs, and we covered for each other during vacations.

I did the math, counting call hours as work hours: a doctor who offers continuity of care for outpatients and inpatients, sharing with 5 others, puts in, on average, a 70 hour week in the unlikely event he or she can keep the office hours to 40.

But this town has mills and mines, and pipelines and power lines cross the area. Diesel mechanics, millwrights, pipeline management, electricians, first aid workers, linemen, engineers and even truckers all have call schedules.  No piece of equipment can run 24 hours a day without breaking down, yet the big employers all run 24 hours.

The physicians get respect here because so many of the mill hands, with or without call, work in the middle of the night. We know what it’s like.  Locally, a lot of people have call worse than the doctors’.

I see the health fallout. Sleep deprivation leads to loss of emotional resilience, which in turn compromises immune function, worsens depression and migraines, and aggravates tendencies to substance abuse.  And, not surprisingly, sleep deprived people have more accidents.  For those people on the night shift who contract illnesses that could further impair their concentration or manual dexterity, I tend to err towards back-to-work slips that give an extra night of rest.

Add to everything else the Canadian cold season. Winter’s official first day still remains 6 weeks in the future, but the snow that fell this last week will not melt till spring. We have double digits below freezing and slick roads.  Inadequately rested people behind the wheel on icy highways might not fall asleep, but minimally impaired reflexes lead to rollovers, and one of my colleagues dealt with 4 of them in one night last week.

Yet today I took care of a trucker who retired after 62 years behind the wheel, having never crashed nor gotten a speeding ticket. Because such a unique record could identify the patient, I asked for, and received, permission to write about it.

Small non-miracles

November 1, 2018

I don’t believe in my aura

At least I don’t any more-a

I can’t tell you why

A bird will fly and not die

When I pick it up from the floor-a

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.

I took care of a patient today with a physiologically unlikely (but not, as it turned out, impossible) complaint. Before I had the chance to research, and while I kept my skepticism concealed, I established rapport with the patient and, in the process, learned to use a medical instrument I’d never seen before.

When the world started the change to digital, I ran into problems.  I stopped the first digital watch I bought in 1980, and kept stopping them for another 10 years.  After that they didn’t stop so much as the batteries died quickly.

When I came off the Acoma Reservation in 1985, the first electronic cash register I encountered malfunctioned at my approach.  I attributed the stoppage to the inherent fragility of new technology, but the trend continued for another 12 years.

Our youngest daughter ran into the same problems and to this day kills digital watches.

I do not believe people have auras, and thus I find it hard to account for the fact that digital devices used to break down consistently in my presence.

But, to build rapport, I told these stories to my patient, who also stops digital watches.

She has a way with animals, and she catches birds with her hands.

I recounted the time that a bird flew into our picture window, while our children, age 7, 9, and 11 watched.  The bird dropped to the patio, and the kids immediately demanded that I, the doctor, go try to revive the apparently dead bird.  I picked it up, it regained conciousness, and flew away.   The kids showed no surprise.  I tried not to, either.

My patient told me that I’d done the right thing.  A stunned bird righted will generally come to, but if left supine will die.  If your patience wears out before the bird flies, she said, place it upright in a box or other structure that will keep it upright, and most will live to fly.

I hadn’t known that. I asked for, and received permission to put that information in my blog.

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I came to realize that taking call has all the earmarks of an addictive process, and wrote about it in another forum.  Other people, besides doctors, take call.  In the context of symptoms that could be psychological or physiological, I talk to patients about what addictive processes have in common.  This particular patient agreed vigorously.  I printed out my essay and handed it over.

I had call the night before, and it went badly.  I have suffered adverse consequences because of call, and missed time with my family.  Call has made me physically ill.  As the years go on, I spend more and more time recovering from call.

But I keep doing it.

I felt like the biggest hypocrite in northern British Columbia.

Appreciating normal: brain tumors, radiation, and the adolescent idiocy of love

October 29, 2018

We don’t know when our career starts careening

Insight is hard when you’re leaning

So slowly life sours

Working too many hours

Contrast is the essence of meaning.

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.

Yesterday a patient (who gave me permission to use as much of his information as I care to) came in for a refill of his prescription for lamotrigine (trade name, Lamictal).

My wife takes the same drug, and their stories carry a lot of parallels.

Dizziness brought my wife to MRI in the summer of 2016. A message on a Friday contained the diagnosis of glioma.  Until the proper diagnosis of meningioma came on Tuesday, I thought my world would collapse in less than 60 days.  During that critical 96 hours I learned how much I love my wife, and since then I’ve enjoyed the adolescent idiocy of being in love, and secure with the woman I married in 1980.

A year after one radiation treatment, my wife started having headaches preceded by a smell and some music; verapamil didn’t help her but lamotrigine did.

My patient’s tumor involved more radiation treatments, and he takes lamotrigine for similar but not identical reasons. He emerged from his treatments a happier person.

I didn’t tell him how, when my wife talks, I smile and listen so attentively that it unnerves her. I savor those moments of normality.

I didn’t tell him that the delight I have in the companionship of my mate stands in contrast to my years of working 84 hours a week. But that contrast remains the essence of meaning.  My time with her now is sweeter for knowing what I missed, and that knowing comes from a close brush with loss.

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The very next patient also grinned his way through the visit. He gave me permission to quote him: “I found some awesome words in my career path. Words like floor, walls, roof, and the best one, heat.  And an open and closed sign, that’s another good one, too.”  He had worked for 11 years without those things.

But I didn’t ask permission to discuss his career changes. Doctors are not the only ones who have trouble setting boundaries, and we’re not the only ones who decide to come in from the cold, whether literal or figurative.

Livers and lotteries

October 26, 2018

You could be a taker or giver
There’s a chance, but only a sliver
You probably won’t pick it
So don’t buy a ticket
Thus to keep a healthier liver.

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.
Abnormal liver tests dominated yesterday’s clinic. Each patient had a different problem, and each went into a different management plan.
The most common liver poisoner, of course, is alcohol. But if a patient credibly claims alcohol avoidance, I have to look for other exposure to alcohol or other organic solvents. I have found a disturbing number of people with medical problems from breathing vapors of Lysol Spray, a product containing 95% alcohol. (Regretfully, many years ago I took care of a patient who later died from liver cirrhosis caused by drinking Lysol Spray.)
Too much food can damage the liver, just like too much alcohol. When rich food has, in the whole of human history, never been so cheap or convenient, NASH, (non-alcoholic steatohepatitis) now ranks second to alcohol for damaging livers. Within the last ten years one of my patients died of cirrhosis caused by overeating.
I still check for hepatitis A, B, and C though a result from those tests hasn’t surprised me for years.
About 1 in 50 people carry the mutation for hemochromatosis, where a person’s DNA fails to code for a signal to quit absorbing iron after having enough. The excess iron ends up in the liver.
Much as a person born with the mutation for continuing iron accumulation after storage reaches saturation, some people don’t know when they’ve had enough alcohol, or food. And some don’t know when they have enough money.
To be rich you must be content with what you have, and, really, without the capacity for contentment a person will always have the drive to acquire more even when not needed.
Even contentment does not suffice to make a person rich. I have met retirees with pensions who have no interest in acquiring more, but they get into trouble precisely because they have enough to keep them from want but they have nothing to do with their time.
The day dominated by liver patients started with news from the US about a lottery jackpot of more than a billion dollars.
At breakfast Bethany and I remarked on the sum, and I said that a pot that large might tempt me to buy a ticket.
Lotteries ruin lives. Losers spend money they can’t afford and find in their losses an excuse to not be happy. Winners gain weight, get divorced, lose their moral compass and see their loved ones die.
So I don’t buy lottery tickets for fear I might win.
But a billion dollars? I could blow it building a medical school to my vision: Hire the most gifted teachers to generate cognitive content for premed and the 2 classroom years, and post online courses at very low cost. Weed excess students by requiring fluency in a second language. Anyone passing Part I of the Boards could apply for a clinical position.
Or, alternatively, I could just keep doing what makes me happy.
And I don’t even have to buy a ticket to do it.

Students playing with slit lamps

October 25, 2018

It’s as simple a one as you’ll find
And I hope that your teacher is kind
Concerning the eye,
Here’s the how, not the why
And playing beats the old grind

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.

Most doctors who take call have superstitions. We talk about not using the “q” word (quiet); to do so seems to bring disaster in the form of swarms of sick patients.

Personally, I will not answer a question about how call is going till I can do so in the past tense; I always say, “Ask me Monday.”

I can now say that call went well. I had the great pleasure of having 3 med students.

I asked the students to gather at the ER at 8:00AM, expecting a patient who didn’t show. With no clinical load, and no time pressure, I introduced them to the slit lamp at 8:30AM.

A slit lamp is, essentially, a stereoscopic microscope for examining live eyes in real-time. In larger centers, with ophthalmology (eye specialist) back up, the generalist has no need to learn to use one.  Because I shy away from those jobs, I have had to learn to use the instruments, and I did so by playing with them.

Slit lamps come in a variety of conformations and complexities; the one we have here appears old, simple and wonderfully functional by comparison to the slick, spiffy ones I’ve used in Alaska.

I showed the students the joy stick that enables a doc to focus on different eye structures, and the switch that changes the light playing on the eye from slit (hence the name) to circle to black light. Then I sat on the patient side of the instrument, put my chin and forehead in the right places, and, one by one, talked the students through the proper use.

Actually, I said, “Take off your glasses and have a play. This is about as simple a slit lamp as you’ll ever find.  We have no time pressure, you have complete support from everyone in the room, and you can’t hurt anybody.  Go for it.”

At the end, 5 minutes of play trumped the half-hour of didactics I didn’t  go into.

After we’d all played with the instrument, they asked when to use the slit lamp. “That,” I said, “Is a much longer talk and is best reserved for your ophthalmology rotation.”

I told stories about grouchy specialists and foreign bodies embedded in corneas. Eventually, I talked about Reiter’s syndrome: inflammation of the eye, urethra, and joints, frequently accompanied by fever and rash.

But I didn’t tell them the whole story about Reiter, a Nazi who did such terrible things in World War II that many in the medical community would like to use the term “reactive arthritis” and make the eponym anachronistic.

We were having too much fun playing with medical instruments.

 

 

Looking for the illness behind the addiction

October 24, 2018

I saw some addicted to meth

I want them to keep up their breath

And not lose their molars

Because some are bipolars

Predisposing to a too-early death

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.

I dealt with a number of methamphetamine addicts today.

Far too often the medical profession in general and this doctor in particular yield to the temptation to judge substance abusers. Such an exercise in self-indulgence on the part of the physician fails to benefit the patient at the same time it saps the energy of the doctor.  I learned those lessons from a doc 18 years my junior.  I wish I learned it earlier in my career.

Most physicians find it easier to focus on the human being in the substance abuser if we also can find a major psychiatric diagnosis.

People do not decide to acquire the diseases of schizophrenia or bipolar (formerly known as manic-depression); such illnesses come to them gratuitously. And, if they had the choice, almost all the sufferers would choose to be sane.  Society in Canada and the US has failed the mentally ill; in both countries they comprise a disproportionate number of the prison population and the homeless.  All over the world, they face a life expectancy 20 years shorter than average.

Thus, confronted with an addict, I’ve started to ask my touchstone bipolar question: “Have you ever had an episode lasting at least 4 days during which you felt great without drugs, slept less than 4 hours a night, and didn’t miss the sleep?” If I get a blank stare, I ask, “Have you ever felt so good without drugs that you didn’t need to sleep?”  and if I get a positive answer, I ask if it lasted more than 4 days.

All the meth addicts I attended today met the diagnostic criteria for bipolar. Each one came from unique circumstances, had unique considerations, and got a different treatment.

During my 3 years in Community Health I took care of a lot of the mentally ill. I learned that schizophrenia, bipolar, and substance abuse overlap so much that trying to tease them apart for therapeutic purposes comes close to useless hairsplitting.

I hadn’t learned those things during my private practice years because that patient population lacks the resources to access upscale medical offices: for the most part they have no insurance, money, or transportation. Too many of them constitute the homeless and the incarcerated.

So I did my best. I prescribed the patients medication and asked for follow-up.  If they don’t come back, I won’t think less of them, because their illnesses include impaired thinking.  And I won’t think less of myself.

 

ATLS: because real emergencies don’t give you time for an open-book test

September 5, 2018

 

Between the chest and the lung there is air

You don’t have an hour to spare

To consider the drama

Brought on by trauma

One must think, in spite of the scare

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

Friday I attended the Advanced Trauma Life Support (ATLS) refresher course in Lincoln, Nebraska.

The summer showed signs of drawing to a close on the trip down.

The geese, having spent the spring mating and then hatching, and the summer nurturing, flew training flights with their broods. The mass migrations south won’t come till later.

The corn, which shot up so green against the brown earth in June, has come to the end of its life cycle; some fields losing their green at the edges, and a few already dead and drying down for harvest.

The ATLS requires renewal every 4 years; I decided to go a year early.

I hadn’t forgotten as much as I’d thought. The morning lecture went quickly.

I chatted with my colleagues at lunch. On my left, a doc married to a doc plans to retire as soon as he can but doesn’t have an idea about what he’ll do then.

On my right, a well-preserved physician declared that she does locums to ease into retirement. We asked each other about ultimate plans but neither had a good answer.

The written test preceded the skills station.

Anyone who finishes med school excels at written tests. All the homework, papers and exams of secondary and higher education just prepared me for the next 40 years.  Every day I write (or dictate) essays.  Last year’s 200 Continuing Medical Education (CME) hours involved lectures, reading, and quizzes.

The real world gives open-book tests. Most of my daily clinical challenges give me time to look up answers. Real emergencies don’t, and the ATLS prepares the student to keep cool thinking in times of terrible crisis.

I proceeded on to the clinical simulation; the examiner sat on a chair and presented a scenario: alcohol-mediated single car crash with victim ejected and now in my ER with low blood pressure and oxygen, distended neck veins, and no right-sided breath sounds. The model victim, a live person, lay on a simulated gurney.

“Tension pneumothorax! Needle thoracostomy!” I cried, because doctors talking to doctors can’t say “Collapsed lung!  Run a needle over the top of the 2nd rib to release air so it re-inflates.”

The rest of the case came frighteningly close to a blend of the two trauma cases that inspired me to take the course early.

I was the last to finish my clinical simulation, but still 2 hours earlier than planned. Which gave Bethany and I time to do some leisurely grocery shopping in Omaha on the way home.

 

 

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.