Archive for the ‘Canada’ Category

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.

 

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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.

 

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.

 

Speechless during a speech

February 20, 2018

I stood up to give a talk

And then a Canadian doc

Said “You may want to switch

To a province less rich.

It might be a bit of a shock.”

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. I’m taking some time off after a month of part-time (48 hours per week) work in northern Iowa. Any identifiable patient information has been included with permission.

I originally went to work in Canada to learn about the medical system first hand. Of course I want to share the knowledge, and I put together a half-hour lecture for the County Medical Society.

I managed to arrive at this late date without learning Power Point. But having adapted to 15 electronic medical record systems in the course of 3 years, I figured that putting together a PP presentation couldn’t be very difficult. And, indeed, in less than an hour I found myself creating slides and downloading images from the Internet.  My brother, an accomplished graphic artist, provided me with two illustrations.

American physicians do not want to hear that the current Canadian system is better for the doctors than the American system, especially not the ones who came from Canada. I hasten to say that the systems now are not what they were 20 years ago or even 10 years ago.

Still, a Canadian ex-pat pointed out that I had chosen Canada’s most prosperous province (which I hadn’t realized), and that least-prosperous Nova Scotia might have given me a different view-point.

Over the next 3 days, I talked to 3 American doctors far from burnout. Two of them, both in their 60s, have refused to acquire electronic medical record systems.  One refuses to take insurance.

A week and a half later, I gave a slightly different version of the same talk to first- and second-year medical students in Des Moines. The audience’s palpable idealism impressed me, and I pitched my presentation to those struggling with the basic sciences.  I advised them that burnout is a very real problem.

The early warnings about burnout happened early in my medical school career. The dean of the med school, in the first week, told us that if we didn’t take care of ourselves eventually we’d be of no use at all in the medical system.  I don’t think he could have foreseen the escalation of burnout now threatening the system, nor that it would come not from emotional exhaustion, but from frustration with electronic medical record systems and overreach by management and government.

Twenty minutes into my talk, my phone gave me a text chirp. I ignored it and kept talking.

At the end, I took questions. One of which, almost word for word, got asked at the County Medical Society meeting:  What one single, practical thing can be done to improve our system?

Go to a single level of service, I said, instead of the 5 that we have now.

I got four questions from the audience, three others on 3×5 cards, and five more as the students exited on their way to the next class, snagging leftover pizza.

Then I looked at my phone. My physician daughter had given birth to her second child, a daughter.

And then, for about five minutes, I was speechless.

It doesn’t happen often.

 

I joined NIRD

December 20, 2017

I think that what you have heard

Could be boiled down to a word

The truth I must face,

And even embrace

Is the fact that I’m really a nerd.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.

No one called me “nerd” in high school, only because the word hadn’t come into currency. I belonged in the clique of intellectuals that didn’t have a clique. I figured out pretty early that I’d rather study than party, read a dictionary than drink, and find a movie’s logical inconsistencies and anachronisms than sit back and enjoy it.   By the time I could relax and embrace my nerdiness, I knew how to find groups that valued and even revered book learning.

So I jumped at the chance to join Northern Interior Rural Division of Family Practice, or NIRD and the chance it offered for a Christmas party and an opporutnity to get together with other rural docs. I even ignored the misspelling.

True to my inner nerd, I got us to the party on time at 11:00AM, and before anyone else.

Most physicians brought their families and most of the kids were younger than 12. I probably graduated from med school before half the docs were born.

I gave a yoyo demo. Bethany and I repaired an 11-year-old’s yoyo, I gave him a new string and taught him how to wax it to improve the sleep time.

The docs from our clinic, with spouses and kids, settled at one table. To my surprise and delight, we didn’t discuss patients.

We had a great meal, centered on turkey but with plenty of vegetables. We didn’t rush dessert, and chatted on after everyone else had left.

At 3:00PM, little daylight remained. Bethany and I picked out a movie, but couldn’t find the theater in the dark despite 3 GPS units.

We stayed overnight in a rather nice hotel room. I’d never seen glass interior walls that opacified for privacy.

The next day we bought groceries at Costco and Real Canadian Super Store, which vies with Costco for great prices but offers a better selection.

Without the rampant Canadian politeness, we probably wouldn’t have escaped from the parking lot of either store before closing time.

We had a beautiful drive back, with clear skies and bright sun, and fine, gleaming white frost on the trees.

 

 

Why the nicotine patch fails, and what to do about it.

December 17, 2017

The smoker should take part of a straw

Through which, when breathing, should draw

For the smoking cessation

It bring relaxation

And that, with the patch, is the flaw.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.

 

I hate tobacco with a passion which I restrain to as to not alienate patients. I ask people, on a scale of 1 to 10, how ready they are to quit.  If they say 1 or 10 I move to another topic.  If they say anything else, I ask them to tell me why they aren’t LESS ready to quit, and to name the best three things about smoking.

Smokers most commonly say “stress relief” as the best thing about smoking. I used to argue, pointing out that smokers smoking have the same level of stress as non-smokers at baseline; the stress the patient felt, I would say, comes down to nicotine withdrawal.

That approach didn’t help anyone quit; if anything it hardened the person’s commitment to death by tobacco.

Recently, I have started to point out that if a person wants stress relief, the deep breathing exercise that every smoker has mastered brings half the stress relief of smoking. Inhale like you’re getting the best drag of the day, I say, and your stress level will go down.

(Recently the FDA approved a device to treat high blood pressure.   Really an app, it gets people to slow their breathing.)

I think the nicotine patch fails so often because the people don’t get the stress relief of deep breathing.

Today, a patient who had already figured out that strategy announced he planned to get some straws and to breathe through, to give him something to do with his hands.

And, just like that, within an hour I had two more patients intending to quit smoking.

I advised both to get a soda straw, cut it in half and carry the half where they carry their cigarettes. And to breathe through the straw as if smoking a cigarette.

This simple, brilliant technique will answer the habit strength question, help with stress management, give the person something to do with their hands which also includes the mouth, and give the person much the same velocity of air as breathing in through a lighted cigarette.

 

The First week back in Canada

December 10, 2017

Oh, the joys of that 12th vitamin B

A low makes me dance round in glee

For without scalpel or knife

I can save someone’s life

And the med costs a very small fee.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.

Though scheduled for orientation on Friday, I remembered a good deal of the electronic medical record (EMR), and started in with walk-in patients at 10:00AM. By the end of the day, I’d attended 11 people, as good as my best 8 hour clinic day during my most recent month in Alaska.  Patient flow goes very well here, documentation comes easily.

I carry the title locum tenens, which means that I’m a substitute or a temp, and only the night before did my name fall onto the schedule. Yet I knew 4 of the patients I took care of.

Monday started a very good week. I enjoy patient care, but I know that seeing too many patients in too short a time brings too much stress.  I saw a decent number of patients, rarely ran more than 10 minutes late, got lunch every day, and finished my documentation before 5:30 PM.

Filling in for two docs, at one point I had more than a thousand lab results to sign off.

An unusual percentage of the alcoholics I saw recognized the problem, and an unusual number of smokers had already decided to quit. Although, in fairness, an almost identical number of smokers had no interest in stopping.

I took call on Thursday to Friday morning. I slept poorly as much from the emergency at 3:00AM as from zigzagging time zones.

Friday more than half my patients represented repeat business. The clerical staff informed me that when people learned of my impending return, they waited to schedule with me.

Three of those patients had vitamin B12 deficiency. One of them gave me permission to write about the thrill I get from running the right test at the right time and finding that diagnosis.  I don’t often get to save a patient’s life, and, with B12 deficiency, I get to do it for pennies a day.

B12 deficiency most commonly presents as fatigue. In the past I started the investigation on the basis of depression, anemia, numbness, gait disturbance, erectile dysfunction, ADHD, and dementia.

In other clinics, management has discouraged me from ordering B12 assays in the Emergency Room or Urgent Care contexts. Yet, finding a result in my lab queue with that critical L beside the number brings me disproportionate joy and gives me a goofy grin for the rest of the day.

Which is why I prefer positions where vitamin B12 measurements are appropriate.

Learning about a new toxic inhalation

August 22, 2017

It’s been quite a while since Yale

Some of my knowledge went stale

For I’ve never been tried

On chlorine dioxide

When it comes to the stuff you inhale.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

This town depends on forest products and, to a lesser extent, mining.   Felled trees get trucked or floated to the industrial area just outside of town, to get sawn at the lumber mill or chopped and bleached at the pulp mill.  The wood useful for neither process gets burned as biofuel at an electric plant.

The pulp mill operates 50 weeks per year, with a two-week shut down at the end of each summer for preventive maintenance and cleaning. The usual work force gets supplemented by short-term workers and contractors with their crews.

The cadre of workers may have experience, but all change involves chaos, and from chaos comes hurt.

Today, I saw a patient who had inhaled chlorine dioxide, ClO2, referred to by its local name, clowtwo (rhymes with crow brew) the day before, and gave me permission to write a good deal more than I have.

Decades ago, I worked in a town that relied on the meat-packing business. That industry requires a lot of refrigeration, which in turn depends on ammonia.  We did a lot of workman’s compensation medicine at the time, and one day I had four workers brought in simultaneously for ammonia inhalation, from a refrigerant leak.

Had I been asked, I would have diverted all 4 patients to the Emergency Room, but I hadn’t had the chance. I immediately had one nurse start oxygen, another nurse call for 2 ambulances, and a third nurse inject steroids.

When I called the ER to request a transfer, I could say, honestly, that they were breathing just fine and wondering why I was so worried. By the time they arrived at the emergency room, all 4 were starting to drown in their own fluids.  They all survived, after close to a week in the ICU.

I dealt effectively with a tough situation because I had read up on the effects of ammonia on the lungs beforehand, and I knew how dangerous it could be.

In this case, I knew a good deal more about chlorine inhalation, because of its use in WWI, but I didn’t know about chlorine dioxide and I hadn’t read up on it. The patient helped me along as I clicked my way through the Net, giving me the benefit of his experience.