Archive for the ‘Canada’ Category

Vice-Grips as a surgical tool

December 10, 2018

He came in with a tree in his heel

I didn’t ask, How do you feel?

But I got a good grip

At the end of the stick

And yanked.  And I did it with zeal.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, 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.

People sustain damage in such unlikely ways I would be ashamed to write them into a script. The young man involved gave me permission to tell his story.

Working in wilderness areas where bears and wolves constitute more of usual hazard than anything on the ground, he stepped off a log onto another, not realizing that a dead branch projected directly into his landing zone. The sharp piece penetrated the industrial-rated sole of a new boot in good condition, into the foot just in front of the heel bone, and exited right next to the outside ankle bone (lateral malleolus, if you must).  He crawled 300 meters (three football fields with end zones).  His boss drove him 4 ½ hours to our facility.

The thick end, about half an inch around, stuck out half an inch from the skin.

Of course I called for help. The orthopedist in Prince George advised us to remove it, give the patient antibiotics and pain pills, and make sure he arrived ready and in time for surgery the next morning at 8:30AM.

I know a lot about procedural sedation, but I’ve not done one, so I called for more help.

While I waited, I got to thinking about exactly how to grasp the spear at its base. I located the biggest needle driver and the toughest-looking Allis clamp, but neither appeared up for the task and I wished out loud for a pair of Vice-Grips.

Check Maintenance, the nurses said.

Finding the Maintenance door locked, I discovered to my amazement that my key for the Doctors’ Lounge opened it. From the drawer marked PLIERS I extract a Vice-Grips, a Channellocks, and a pair of industrial-grade Stanley pliers, thinking that all those years as a bicycle mechanic finally paid off.

My colleague graciously came in, talked me through the anesthesia set-up, and watched as I administered fentanyl (a powerful, short-acting narcotic), and propofol (a general anesthetic). When the patient quit answering questions, using my experience with Vice-Grips and metal, I got a loose fit, tightened the locking pliers half a turn, grasped the projecting end of the stick and yanked.  The stick exited cleanly though blood-covered, just a bit longer than my palm’s-width.

Despite heavy anesthesia, the patient sat up and talked without making sense, then after 15 seconds lay back down. When the general anesthetic wore off, he did not remember.

I brought the tools back to Maintenance, and took a good look at their tool drawer.

tool drawer december 2018

Note the needle driver, hemostat, and surgical scissors juxtaposed with Vice-Grips, Channellocks, wire strippers, and tin snips.

Contrast is the essence of meaning, especially in a hospital maintenance department.

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Gentle cold and frustrated pagophilia

December 4, 2018

So rare has the story been told

You can ask, is it fool or bold?

Those pagophiles

Travel thousands of miles

Trekking north to seek out the cold

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.

A thermophile, one who loves warmth, doesn’t deliberately head north after the autumnal equinox. In fact, such a person would go south in the winter.  The language has acquired a term, snow bird, to refer to the millions who yearly flee the snows of the north.

So rarely does the opposite migration happen that I didn’t come across the proper term, pagophile (a person or thing who loves cold), until a few months ago, in a book describing people who deliberately set out to experience the Polar Regions in the winter.

Bethany and I discovered our pagophilia in the winter of 2011, when we landed in Barrow (now Utqiavik) a week before sunrise.

We arrived here in northern British Columbia in October, and though we had a dusting of snow early on, gentle cold has prevail with the temperature has hovered around freezing for the last couple of weeks. We’ve had some more snow, but we’ve also had rain.

In the last four days I’ve enjoyed the plunging mercury, finally in the negative double digits Celsius (about 14 Fahrenheit). Snowflakes fall dry, but I’ll have to wait for colder weather to frost my beard.

We’re still sleeping with the heat off and the window opened a crack.

+-+-+-

A lot of Americans complain about the US Postal Service, but in fact the US delivers packages reliably in less than a week. Even during the December retail madness, a slow package arrives in 2 weeks.

Canada mail moves slower, perhaps because of greater distances, sparser population density, or less well-developed roads. Or maybe we have a distorted view because the mail has to go about 500 miles from Vancouver to Prince George, (about the same distance as Sioux City to Dallas) before it can get loaded onto trucks for delivery out to the smaller towns.

Right now Canada Post faces a “rolling strike” by workers in 4 major cities, Victoria, Edmonton, Halifax, and Windsor. Theoretically, the workers only strike 24 hours at one of those centers before moving on to the next, but in fact the work stoppage has slowed parcel delivery down from its usual laid-back stroll to a crawl.  People talk about ordering from Amazon, prepared to email pictures of presents.

Of course, any package attempting to cross the border will run into a time warp worth of a science fiction story.

Malignant materialism: Black vs. Plaid Friday

November 26, 2018

Thanksgiving? Not all that you’ve heard

And the turkey’s a much larger bird

A gift for your grad?

For Friday’s now plaid.

For the local business assured.

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 celebrates Thanksgiving the second Monday of October. Feasts commonly include turkey, squash, vegetables, and apple pie; regional variations include salmon, wild game, Brussels sprouts, wild rice, unique local foods, and what Americans know as New England boiled dinner.

The narrative of the Canadian First Thanksgiving has to do with Martin Frobisher’s successful landing with more than a dozen ships on Baffin Island.

The US Thanksgiving holiday comes the third Thursday of November. The common story of the first Thanksgiving includes the Pilgrims inviting the Wampanoag to a meal celebrating the first corn harvest.

Not surprisingly, the Wampanoag tell a different story that sounds more likely, having to do with irresponsible celebratory gunfire, checking the wellbeing of the vulnerable English, and fishing and hunting in the process. Particularly ducks, geese, turkeys, and deer.

Deer haven’t changed but turkeys have. Since 1950, average slaughter weight has more than doubled, from 13 to 29 lb.

The holiday itself has morphed with the times; religion, hunting and gunfire for the most part have dropped away, replaced by a prolonged, sedentary feast followed by a commercial feeding frenzy. All with a prolonged football binge.

Canadians, like their southern neighbors, kick off their big retail season with the day after American Thanksgiving, calling it Black Friday.

I went to work this year when my friends and relatives in America went out of their way for arguably the biggest meal of the year.

I found it a day to be thankful, without overeating. A hospital patient went home.  I got along with my wife, my colleagues, my patients, and my co-workers.  I walked from a decent dwelling to a decent work place without fear for my physical safety.   I got to see patients improving, and I witnessed the miracle of more addicts coming to insight.

The next day my arrival in clinic started with an accusatory, “Where’s your plaid?”

“P-plaid?” I asked, noting the surrounding tonsorial color scheme indeed dominated by plaid.

Plaid Friday, they told me, celebrates buying locally.

I shrugged. I don’t own anything plaid in Canada.  My general abhorrence of malignant materialism, combined with hundreds of snow-packed kilometers between me and the nearest Wal-Mart made supporting Plaid Friday easy.

Finding myself on call till 6:00PM qualified as the biggest surprise.

 

 

 

Fingerprinted by the Royal Canadian Mounted Police

November 22, 2018

The Constable, he offered a link

He was trained, thank goodness, in ink

A true pro, that Mountie,

He declined my bounty

And we agreed on the evils of drink.

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 went to the Royal Canadian Mounted Police to get fingerprinted today.

I had my finger prints taken first in 1970 by the Sheriff’s Department in Geary County, Kansas, having been booked on the charge of Illegal Pedestrian. (Neither the Court nor the Sheriff has a record of the offense.)  The Indian Health Service required another set in 1982.

Between the summer of 2010, when the Samuel Simmonds Memorial Hospital management sent me to the police department of Barrow (now Utqiaviq), Alaska, for 4 sets of prints, and the summer of 2015, the fingerprint paradigm shifted. Instead of special ink and paper, the FedEx installation used a digital device.

(That particular installation in Pennsylvania got hacked, and all my personal and security data got leaked, including my fingerprints.)

As I’m applying for a Texas medical license, the Texas Medical Board wants two sets of fingerprints, the old-fashioned way. I had to stop by the Royal Canadian Mounted Police station.

A few of the larger cities in Canada maintain their own police forces, but most jurisdictions find contracting with the RCMP more cost-effective.

I have had nothing but favorable experiences with law enforcement in Canada. The Mounties maintain a unique blend of professionalism with friendliness.

The RCMP branch opened at 8:00AM. I had luck, the Constable had been trained in paper-and-ink fingerprinting before the digital revolution.  I had to give my height in inches and weight in pounds; we couldn’t be sure that Texas would know what to do with metric dimensions.

In the States prints cost $10 to $25, depending on quantity and agency. I reached my fresh-washed hands into my pocket for cash, but the RCMP declined payment.

I told the Constable about my adventures, and my plans to do locums with my daughter and son-in-law in Galveston on the Gulf Coast. Most people like warm climates and the Sunbelt, I observed, but my wife and I thrive in the cold.  Then I talked about wanting to work in Nunavut, the northernmost and largest Canadian territory, but nobody answers my emails.

He has connections in Nunavut, he said, and said he’d send my contact information on. After all, we agreed, not very many docs want to go there.

I left the RCMP station with a bounce in my step, impressed again by an institution that blends professionalism with friendliness. I have hope that the meeting will help me network.

.

 

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.

 

 

Permit, license, insurance, and a contract with the Queen

October 7, 2018

I ended up feeling so keen

For three things, together they mean

I no longer lurk,

But I can come out to work

After my contract I sign with the Queen.

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, my 50th High School reunion, and a 4-month assignment in northwest Iowa, I have returned to Canada.  Any identifiable patient information has been included with permission.

Monday morning I strolled over to the clinic, marveling at my first snowfall of the year.

I had submitted my work permit electronically to the College of Physicians and Surgeons of British Columbia (CPSBC), which they required before reactivating my license.

I got my new passwords arranged. I’ve done 18 new electronic medical record (EMR) systems in the last 4 years, and, having been away from this one for the summer, I spent the morning practicing.  Mickey Mouse’s name turns up as an imaginary patient in a surprising number of EMRs, including this one.  I entered the diagnosis of felinophobia (fear of cats), and practiced ordering prescriptions, lab, and x-rays. I strolled around the hospital and greeted staffers.

I checked my email every 15 minutes for a reply from the College.

I walked back to the hotel for lunch and a nap. Still unlicensed, I returned to the facility.

By the end of clinic hours boredom set in. One of my colleagues called the College on my behalf.

Tuesday came as a replay. Clicking the REFRESH button every 15 minutes doesn’t count as exercise, and by noon I had started to ache from inactivity.

And I didn’t have cases to talk to my colleagues about. I missed being one of the cool kids who has stuff to talk about.

In the late afternoon my email lit up with notification of license reactivation, but I also had the chance to talk with the College about the possibility getting full licensure, making it return more flexible and shorter assignments possible.

I get my professional liability insurance through the Canadian Medical Protective Association (CMPA), based in Ottawa, 2 time zones to the East. So I called them at 6:30 Wednesday morning (8:30 their time), and by 6:35AM I had insurance.

At 8:00AM I strode into the clinic, grinning. In front of witnesses I signed my contract with Her Majesty, the Queen of England, and started into work.

I took care of my first patient of my return before the official start of clinic hours. I got permission to write about the problem, Eustachian tube dysfunction: the pressure in the ears which follows a cold or allergies and for which no effective medication exists. (Insurance rarely covers the only effective treatment, the EarPopper, a device that “pops” the ear, and costs over $300).

PTSD, chronic med refills, adult immunizations, and discussion of complicated endocrine investigations should not come to walk-in clinic. But they did.  At about 10:00AM I had a patient with a true urologic emergency, when I was running and hour late.

The day didn’t get less frantic after that, and I missed lunch.

I vastly preferred the action of the jam-packed day to the boredom that preceded it. And, at the end, I had cases to talk about, just like the cool kids.

 

Talking Canadian Licensure With a Canadian

August 31, 2018

To her home the doc wants to go back

It took time, but she’s facing the fact

She has nought left to prove

So she decided to move

I told her she just needs to pack

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 had a good long phone conversation with a Canadian national, a physician working in the States considering going back home, for a lot of reasons.

Right now she attends patients in a high-crime area with brutal heat and humidity, in the sunniest part of the sun belt. She loves teaching, and she loves medicine.

She talked about her aging parents in Ontario. She asked me about scope of practice and professional climate for docs seeking licensure in Canada.  And how to go about the process.

Honesty seized me. I couldn’t talk about her specialty or academic medicine at all. I could barely talk about big city medicine.  I told her how much I loved my spot in northern British Columbia and what huge hassles I’ve been through to work in Canada.

I couldn’t tell her what difficulties she’ll find getting licensure in Ontario, because Ontario is not British Columbia. After all, my Alaska license came easily, my Pennsylvania license did not.   She will not face the 5 months of ricocheting emails caused by hard-to-read signatures on 35-old-residency certificates, nor another 5 months of frustration caused by accidents of history in the development of Family Practice training.

She probably won’t face a 7-month dead-end with a private recruiter.

She won’t need a work permit because she’s Canadian, and she probably won’t need a physical.

We swapped bits of our backstories. I talked about how my curiosity got me north of the border to start with, but how the practice climate keeps me coming back.

We talked about how the insurance industry and government (under the guise of Medicare) used the Electronic Medical Record systems to steal the joy from medicine. We face rapidly expanding nets of regulations that demand more work but do nothing for patient care.

In the end, we agreed that we love the work despite the administrative hijacking.

When I hear American physicians whine, I tell them they can move, quit, go to Direct Patient Care (where the doc gets paid out of the patient’s pocket), keep whining, or just lay back and take it.

The Canadian internist arrived at the same narrow list of choices, and decided to move back home.

Raising TV-free Kids

April 12, 2018

The visit finished just swell

Not needed were my tricks than can quell

That interruption

That brings conversation corruption

‘Cause the children were behaving so well

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.

A visit with multiple children in the exam room can challenge the most patient of doctors. Those of us with ADHD can find our enjoyment of children threatened by chaos and noise.  I have developed strategies.

I have a yoyo and I know how to use it. I tell any children not involved in the business at hand that I’ll do yoyo tricks if they don’t interrupt; the first trick follows about 45 seconds later, the second one 3 minutes after that, and the interval keeps getting longer.  The strategy works on kids who can’t tell time, and it works better on girls than on boys.

This week I took care of 3 of 4 patients in the room, a mother with her three very young children. The kids sat quietly and didn’t interrupt.  Neither I nor the mother needed to chastise, bribe, or threaten.  I worked through the patients one by one.  While explaining clinical findings, diagnosis and plan to the mother I noticed the middle sibling kiss the older one on the back.  Before I could finish my sentence, the youngest one had kissed the middle one.

When I finished with the heart of the visit, I asked the mother, and found out, that the household had no television.   Then I requested and received permission to write about a family with well-behaved, well-disciplined, loving children raised in a TV-free home.

I congratulated her, and told her my wife and I raised our three daughters with no television. Actually, in the course of time we partly raised 3 others as well, but I didn’t mention them.  We talked about how children love stories and generally prefer them to television.

I didn’t tell her about working in a First Nations community, where I repeatedly saw siblings treat each other with love and respect. Nor did I make the observation that children mirror their parents, and such behavior as I saw spoke well of the way that the parents treated each other and their children.

And I didn’t tell her the real reason that Bethany and I have lived without television: we have a problem with it. If present, we will watch it to the exclusion of eating, sleeping, marital bliss, and parenting.   We are TV addicts, and we do fine if it isn’t available.

 

After two unemployed months, back at work

April 7, 2018

Of the patients there’s never a lack

I can tell you it’s good to be back

I think that it’s neat

When the patients repeat

And I can see that they’re on the right track.

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.

Today I cared for 12 patients, 1/3 of whom I had cared for either last summer or in December. Respiratory problems dominated the clinical landscape, but I also saw 3 who came in to find out test results and five who needed prescription refills.

I recognized the first patient and without prompting opened the visit in French. He gave me a heartfelt grin.

I recognized one patient as a New Zealander by his accent. At the end of the visit I got into geographic specifics, and in short order we started talking about Warkworth (pronounced Walkwith), Leigh (pronounced Lee), Matakana, Omaha Beach, the Kauri Museum, Pakiri Beach, and Whangarei (pronounced Fahnga Ray).

Three patients discussed travel to Mexico, either completed or anticipated.

In December I posted about a patient whom I gave the opposite of my usual dietary advice; she returned to see me today. The plan worked, and the problems related to excessive weight loss disappeared.  We discussed favorable labs, and she requested I write about her in more detail.

A quarter of the patients use marijuana regularly. The only smoker wanted to quit.  Nobody admitted to excessive alcohol.

I did yoyo tricks for my one pediatric patient.

The return to work came as a relief after two months without employment. Including those seeking casual medical advice, I averaged less than 3 patients a week since February 1.  Today I fell into the rhythm of my usual questions: tell me about it, tell me more, what else?

News of my Immigration problems circulated here even before I published my last blog post. Patients, staff, doctors, and bystanders commiserated with me.  I pointed out there are few better places to be stuck than Vancouver.  We all agreed if you have to get turned away at a border, none can beat the US-Canada border.

A lot of people, in the clinic, the hotel, and the mall, asked after my wife, Bethany. She made a lot of friends during our last two stays. I got the feeling people missed her as much as they did me.

It was good to be back at work, in a system centered on patients and not cash flow. And it was good to be with a bunch of my colleagues, talking about cases and learning from each other.

At the end of the day, pleasantly tired from the action, but far from exhausted, I stepped out into bright sunshine and temperatures just below freezing. I had finished all my documentation.  I didn’t have to think about anything else but the weekend.

 

 

Neither best nor worst case

April 4, 2018

The missing piece I would mention

For my hopes were placed in suspension

Now I can stay

Till the second of May

But at least there is hope of extension.

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.

Even familiar travel routine involves chaos.

I don’t pack until the night before departure. I gather my professional gear first: stethoscope, otoscope, yoyo with strings, head lamp and white coats.  Next come seasonal and exercise gear followed by everyday clothes.  Then I ask Bethany to get everything in the suitcase, which she always does, and always to my amazement.

Staying up late to pre-synchronize with my destination time zone comes easily because sleep before travel comes hard.

Freezing rain delayed departure, so I got to the gate in Chicago just as the Vancouver plane started to board.

I arrived emotionally prepared for a glitch at Vancouver Immigration: I lacked one of the myriad moving parts, which could send me back without a work permit and hence without work.

I sat down at the end of a line of fifty people seeking entrance into Canada. I listened to conversations in Hindi, Russian, Cantonese, and Mandarin while I waited.

The agent who helped me spotted the glitch immediately and had me take a seat close by. My case used an inordinate amount of staff time.  Another 50 people came and went.  The agent, noting the dryness of my voice, gave me several glasses of much-needed water.  The afternoon wore on.

The business and practice of medicine punctuated my wait.   A skin lesion photograph sent to a collegium of 3 docs came through.  We asked questions, asked for another picture, and came to a conclusion: probably not fungal, viral, or parasitic and therefore probably bacterial.

I got a welcome call from a colleague, whom I told about my work permit problem. South Dakota, just like rural Canada, maintains a standing shortage of primary-care physicians, and he offered me work if the BC job fell through.

With texts and emails I continued a correspondence to hopefully lead my path back to Alaska in August.

At the end of the day, the agents looked frazzled and ready to go home. They surprised me with the option of staying in Vancouver for 2 days in hopes the missing piece would materialize.  I had feared being put on the next plane home.

I arrived at the hotel and started to hydrate and catch up on email.

Next day Immigration called me back to the airport to issue an unusual short-term work permit, requiring I show up in Vancouver in 28 or 29 days with the permit and my boarding pass for my flight home.

It’s more than I hoped for, giving me a month’s work under wonderful conditions, and leaving open the possibility of extension.