Archive for the ‘Canada’ Category

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.

 

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Why I Came, and Can I Fix the American System When I Get Back?

August 14, 2017

My reasons? I’ve got quite a few

I didn’t want to say I withdrew

My application

But my rationalization

Got me to work with the right crew.

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.

The patient (who gave me permission to write a good deal more about her than I have) asked why I came to British Columbia.

A lot of people ask me that question, and I truncate the truth, too complex for brevity. In no particular order:  I have a thick stubborn streak.  I had a tiger by the tail: see the project through or have to say that I’d withdrawn an application for licensure.  I wanted to spend more of my time taking care of patients and less time at meaningless but marginally lucrative mouse clicking.  I have a sense of adventure.  I wanted to know the truth behind what US doctors vilify and US liberals champion but neither have any experience or knowledge about.

There are more.

So I just said, “I wanted to know find out about the Canadian system.”

As I opened the door she asked, “So, when you get home, are you going to fix the American system?” I said, “No, but the first step is educating the American docs. And I’m not sure they’ll believe me.”

Actually, I don’t think the liberals will believe me, either.

+=+=+=

Last night the smoke from the forest fires drifted into town. The dramatic evening sky progressed from intriguing to eerie.  Finally, darkness fell, thick and hard, two hours early.  The smell of smoke kept me from falling asleep.  This morning we watched the news for two hours to see how close the fires are.

We don’t want the fires to come this way. Too close and the town dies from lack of wood.  Much too close and the whole city goes up in flames.  I wouldn’t want to have to evacuate, and I don’t know which way we would go.

We’re seeing an increase respiratory problems from the smoke. Some people have come in from BC’s largest city, Prince George, because of air quality.

=+=+=+=

Last time I was on call, I saw 14 patients, and 3 diagnoses accounted for 13 of them: back pain, abdominal pain, and left facial pain. The only one not covered by those three complaints came in before the others, and left, cured.

 

Contentment and birthday pizza

August 13, 2017

At the end of a beautiful day,

We caught the sun’s reddened ray

We snacked on raspberries,

Pizza and cherries

And then we went on our way.

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.

Different organizations have different ways of celebrating birthdays. During my New Mexico years, I got used to bringing food for the clinic when I marked a change in age.  I continued the habit into private practice and Community health.  Mostly, I had Bethany pick out a good selection from Panera.

One of my colleagues ticked just a little closer to 40 last week, and a selection of cupcakes appeared in the clinic. And, at the last-minute, he and his wife put together a pizza-based gathering after work.

Bethany and I drove out to his house at the outskirts of town. He has had black bear, grizzly bear, deer, moose, wolves, and caribou in his back yard.  But on this particular evening we contented ourselves with stories of close wildlife encounters.

The docs drove up, one by one. Before the noise disrupted conversation, I showed off my trick of sharpening knives on the back of a ceramic plate.  Till the pizza arrived, we snacked on chips, and sweet cherries freshly picked in southern British Columbia.

We ate the pizza at leisure. I’ve written in the past about how doctors tend to bolt their food because we never know when we’re going to get called away.  These physicians know how to work hard but more than that they know how not to overwork.  We enjoyed our food.  We chatted.  Topics included economics, politics, horticulture, wildlife, and medicine.  We recounted various places we’d been.  Perhaps because of my country of origin, we had some lively history discussions, fortunately none of them mentioned the Fenian raids, where renegade Americans tried to invade Canada shortly after the Civil War.

The day waned, and I relaxed. Forest fire smoke takes the clarity from the air but it makes spectacular sunsets.  In this case, the solar disc reddened well above the horizon, while cool evening breezes mixed in with the heat of the day.  I reclined after a good day at the clinic and in the late stages of a great summer.  I had worked but not too hard, I had eaten but not too much.  I had chatted knowledgeably but without pedantry.  I had sharpened the knives, but no one cut themselves.

I wallowed in contentment, thoroughly in the moment.

After a bit we toured the grounds. We picked raspberries and ate them immediately.  We saw the Saskatoon berry bush, trampled by the visiting bear.  I looked for the peach tree I had seen earlier.

And when the mosquitos came out, we said good night.

 

 

Team Building Experience, Past and Present

July 23, 2017

We played Two Truths and a Lie,

Then had sushi and beer bye and bye

From the end to the start

Team building’s an art

And none of our airplanes could fly.

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.

As I began my second year of residency in Wyoming, the buzz words “Team Building Experience” had just started circulation. Who knows who decided tubing the North Platte would fill that function?  But nobody objected to the idea of leaving town for a day, driving an hour or two, renting truck inner tubes, and getting into a meandering river.

Whoever made the decision hadn’t looked realistically at the time involved. What should have lasted two hours at most turned into a six-hour struggle.  All of us, at one point or another, left the water carrying the tube, swearing never to get back in.  And all of us jumped back in the river.  We all had our reasons, but the most common one turned out to be the sound of rattlesnakes.

I can honestly say no one died, though most of us finished in the gentler stages of hypothermia.

The program wisely decided against further Team Building Exercises for the duration of my tenure. At various times different subgroups held bonding experiences involving large amounts of alcohol and no official sanction.

I don’t know when and if more Team Building Exercises happened.

The office here has Team Building Exercises twice yearly. The clinic closes and a locum takes over the ER.  This time vacations had a couple of the permanent docs absent, and, despite the temporary nature of my assignment, I got invited, too.

We started off with a couple of getting acquainted exercises; one of them called Two Truths and a Lie. We all wrote three sentences on a card, two true and one false.  The group had to figure out the author and to ferret out the lie.

I wrote, “My first college major was Music Theory and Composition. I was an Olympic hopeful in Archery.  I spent 4 nights in jail.”  More people believed I’d been a top athlete (false) than I’d been a composer (true).  But everyone found the idea I’d spent time behind bars plausible, and wanted to know why.  They couldn’t understand what Illegal Pedestrian meant.  I explained it was an archaic Kansas expression meaning Male with a Ponytail.

We went on to build airplanes using nothing other than 3 boxes of aluminum foil. We broke into pairs, sat back to back, and had one person describe a picture to the other person so as to reproduce it.

The last game involved trying to grab an unfolded red napkin from the back of the belt from as many others as possible. I decided to abstain more because of my back and ankles than my age.

After sushi and beer we sat around and chatted and relaxed, something we don’t get to do often.

At the end we thanked our office manager for putting together a great day.

It beat the heck out of inner tubes, rivers, and rattlesnakes.

Fisherfolk and forest fires.

July 20, 2017

If you can’t take the fire, stay out of the smoke

The stuff that makes you wheeze, cough and choke

This great conflagration

Caused evacuation

And perhaps even brought on a stroke.

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.

I had call this last Friday, Saturday, and Sunday, and I’m on call again tonight, Wednesday. Over the weekend I saw so many people with possible or definite stroke that my neurologic exam, thorough but a bit rusty on Friday, was polished and speedy by Monday morning.

I have had to do suturing at least once a day for the last week. I do not anticipate robots taking over this part of my job in my lifetime; especially if children are involved.

Stitching people up brings the opportunity to just chat with the patient, and I got the chance to pick the brains of a couple of really expert fisherfolk. The lakes around here hold some lake trout, ling cod, bull trout, and Dolley Varden.  One person I talked to has never come back without a fish, and more than one told me about great spots to catch 28 pounders.  Of course we call fishing stories just that for a reason.  Still, after I bandage the wound, the cell phones come out and the photos of the fish have been very impressive.  The most common, and the most successful bait around here seems to be bacon.

Every morning and evening, when I enter and exit the hotel, I see the crews that stay here, too. Of course I expect the seasonal workers: the rail crews, pipeline workers, tree planters, and such.  But now I see firefighters rotating off the line, and I have attended a few in the clinic.

Today the raging forest fires brought in the first of what I anticipate will be a long series of people with respiratory problems. Those numbers might take a while to ramp up, but lungs show an acute phase inflammation, over the first few hours to days, and a longer term late phase inflammation that lasts 6 weeks.

The area doesn’t have many roads, and the fires have cut off evacuation routes south. Last week, at the town’s only thrift store (staffed by hospital auxiliary volunteers), Bethany ran into a family who had to flee the fires.

 

Surviving grizzly bear attacks, controlling drug prices, and training a Dragon.

July 13, 2017

The thought that gives me a scare

Has do to with a grizzly bear

For he’s big and he’s massive

And pretty aggressive

And, out here, not terribly rare.

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 travel and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent US 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.

Some people survive events far beyond the usual human experience.

Lightning strikes more citizens of New Mexico than any other state, and when I worked there I met several. The Natives hold such survivors in high esteem; some tribes elevate them, obligatorily, to Medicine Man status.

Alaska, with the highest percentage of licensed pilots in the country, seemed to have a disproportionately large number of people who lived to tell about plane crashes. I met survivors of gunshot wounds there and in Nebraska.

Today I spoke with a person who survived a grizzly bear encounter.

Most of the bears around here are black bears. Though they’ll eat anything, the majority of their diet comes from plants.  They climb trees, and do their best to avoid people.

Grizzlies are different. The largest land predator on the planet, they have an aggressive temperament.

The bear only bit my patient once, then retreated to keep track of her cubs (the person gave me permission to write a good deal more than I have). If you’re in bear country with the inexperienced, before you start out, make sure everyone knows to freeze if a grizzly approaches, and never to run.  Carry either bear spray or a rifle, and be prepared to use it.

I really wanted to talk to the patient about life and work in this area, but my primary job, fixing people, comes first.

-*-*-*

Price of medication exceeds the price for physician services. In the US, the prices have escalated beyond reason, making the drug company stocks some of the best.  Insurance leaves a lot of Americans without adequate medical coverage, and the cost of medication becomes an important consideration.  When I worked Community Health, all our prescriptions went through our pharmacy. The pharmacists determined the formulary (the choice of drugs), and did a good job of containing costs.  The facilities in Alaska have a similar system; in those places the people don’t pay for their prescriptions.

For most in this town, employers pay for health insurance to cover what the Province’s Medical Service Plan (MSP) doesn’t, like medications.  PharmaCare, a government program, buys the meds  for the low income segment.  Only a very few lack money for drugs, and most of those are self-employed.  The Indigenous and Metis (of mixed Native and other descent) have all their drugs paid for.

*_*_*_

Over the weekend the facility got new dictation software installed. The previous version had worked just well enough to let you think you wouldn’t have to proofread, but still made glaring errors.  Today I used the system for the first time, training my Dragon over the lunch hour.  It did pretty well, but, once, when I said Prince George it typed first gorge.

Time off from clinic for Canada Day

July 6, 2017

They celebrate the First of July

Canada’s birthday, that’s why.

On the way back from there

We saw two black bear

And gave Tim Horton’s a try

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.

Canada Day, this year representing the 150th anniversary of the Confederation of  colonies Nova Scotia, New Brunswick, and Canada, passed largely unnoticed in the US, but well celebrated here in Canada.

Bethany and I slept in and strolled over to the Rec Center for the free barbecue, the third so far this summer. But the demographics of the gathering, not the free food, impressed me the most.

Canada can boast the world’s most ethnically diverse population. We saw a lot of Native faces, and a good mix of Chinese and South Asians.  Everyone got along with the famous Canadian politeness.

This part of British Columbia sports a younger-than-provincial-average population. We saw easily a hundred children with almost as many strollers as baby bumps.

Consider how this mix contrasts with southwest Iowa.

Iowa, the grayest State in the Union, has the highest percentages of septuagenarians, octogenarians, nonagenarians, and centenarians. Within the last year, during my two assignments in the southwest quadrant of my home state I had the daily privilege of taking care of a lot of very old, very spry people.  They had wonderful stories to tell.  A few had survived the Great Influenza of 1918.

We eyed the line for the burgers and brats, then strolled over to the skate park to watch youngsters ride bikes and skateboards around obstacles including ramps, stairs, railings, and benches. One young cyclist took a spill.  He got up and tried to ride the bicycle but couldn’t.  He walked it over to his parents , whom we recognized.

Bethany looked over at me and asked if I wanted to fix the bike. I smiled, and we walked over to the trio and explained I had fixed bicycles professionally through premed.  Sure enough, the brakes wouldn’t let go.  I quickly realized the front wheel had done a complete 360, twisting the brake cables, easy enough to rotate the other direction.

The day after Canada Day we took a drive to mile marker 0 of the Alaska Highway in Dawson Creek.   Highway 97 winds through pine-and-poplar forests, over rivers large and small.  I hadn’t seen any agricultural development for a hundred kilometers.  But we crossed a mountain pass, with tortured rocks exposed in the road cuts, and came into a valley on with lush meadows, herds of cattle and horses, an occasional flock of sheep and the odd goat here and there.  From time to time we saw fenced enclosures with hundreds of round hay bales stacked two deep.

Chetwynd hosts the annual World’s Championship Chainsaw Carving contest; competitors leave behind piles of sawdust and exquisite carving. We stopped into the visitors’ centre.

Of course they asked us where we’re from. We explained that most Americans don’t know where Iowa is, having flown over it but unable to name any of the 7 states that share a border.  Surprisingly, the staffers have a friend who goes to University of South Dakota in Vermillion.

In Dawson Creek we took the requisite selfies at the marker for the beginning of the Alaska Highway, 75 years old this year, and lunched on sushi.

On the way back through Chetwynd, we stopped at a Tim Horton’s, a Canadian restaurant chain a notch or two better than McDonald’s, for dessert. We couldn’t stand the thought of visiting Canada without at least trying such a national institution.

We took our time on the way back, curious about the various human installations that appeared out of the wilderness on either side of the highway, mostly to do with the energy industry.

Just 15 kilometers shy of our hotel, two black bears crossed the road, taking their time, but not quite slow enough to get out the camera.

 

Lower blood pressure with deep breathing

July 5, 2017

It’s a technique, and I don’t mean to brag

But when the smoker lights the first fag

And breathes deep and slow

Though the smoke is the foe

They’re champs at that very first drag.

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.

I see a good number of people with high blood pressure, some better controlled than others. If the pressure is too high, I repeat the reading.  A second round of measurement less than 5 minutes after the first will give a falsely elevated reading.

Most of those with hypertension (a blood pressure greater than 140/90) smoke tobacco and drink more than healthy amounts of alcohol. I point out to the smokers that they have a valuable tool, that they didn’t realize they had.

I was still working for the Indian Health Service when I had a conversation with the worst nicotine addict I ever met. She had quit 4 packs per day about 10 years prior.  Half the relaxation of the cigarette, she said, is the deep breathing technique that goes to taking the first drag.  Every meditation system in the world stresses the deep breathing that all smokers have taught themselves.

Breathing can change blood pressure a lot. The FDA approved a device to teach people to slow their breathing down; the studies showed it safe and effective for blood pressure control.

So I tell the patient to pretend they’re taking the first puff of the day, to breathe slow and deep, and I breathe with them.

I repeat the blood pressure measurement after 6 deep, slow breaths, and almost always the top number drops by 30 points and the bottom by 15, good enough for most people. Whether the improvement is adequate or inadequate, I tell the patient to breathe slow and deep for 20 minutes a day, whether in one chunk or twenty.  For those current smokers, I point out that they could get half the calming effect of tobacco just by doing the breathing exercise that they already know how to do.

+=+=+=

I had call last night. With light traffic in the ER I managed to get back to the hotel early, but I got called back at 10.

As far north as we are, I walked to the hospital with the setting sun in my eyes. Forty-five minutes later, I walked back in the twilight, thinking that I should have brought the bear spray with me.  I crossed the highway with literally not a single vehicle moving.

Learning about the timber industry

June 28, 2017

The market for trees comes and goes,

A boom and a bust, I suppose

At the end of the caper

Logs get turned into paper

And you can watch as the baby tree grows.

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.

My education in the tree industry proceeds.

When the US economy tanked in 2008, this town felt the impact. The housing bubble burst, the demand for new houses dropped and with it the demand for lumber.  At the same time, electronic publishing cut into newspapers and other print media, so that the demand for wood pulp went down, and the local jobs evaporated.  Some people stayed, but more than half left.

The market for tree products has gradually improved since. Logs get chipped, the chips get bleached and cleaned and cooked to make pulp, which gets spread into sheets, dried, and sent to China.  Rumor has it that China turns it into toilet paper and sends it back, but undoubtedly it has more uses.

The trees around here suffered from the mountain pine beetle a few years ago. Normally that insect just takes out trees about 80 years old, but fire suppression and lack of logging shifted the ratio of old trees to total trees.  Then the area had a succession of warm winters with a resultant improvement in larva survival.  The warm winters went with dry summers which weakened all the trees, which then succumbed to the beetles.

Some trees stay green for a few years after they’ve effectively died, and get used for lumber. Dead trees retain lumber value for several years, and after that they become fodder for the pulp mills.  But those who log must, by law, replant.

The only tree planter I’ve met so far has been doing other work this century, but replanting involves a shovel and remains unmechanized.

Once cut and trimmed, logs may be trucked directly to the mill, or otherwise moved to a body of water. Secured with cables into rafts or contained with booms, they might move more than 200 miles before meeting the saw or the chipper.

Lake Williston, the largest reservoir in British Columbia and the 7th largest in the world, transports a lot of floating timber, even in the winter, when an icebreaker moves the logs.

And everywhere that logs move, people move with them. I see the consequences when humans face the tyranny of Newtonian physics:  a body in motion tends to remain in motion, a body at rest tends to remain at rest, and two bodies cannot occupy the same place at the same time.

June 25, 2017

They come in, right off the street

The problem it seems, is the feet

And then when the pain

Makes them complain

Orthotics just can’t be beat.

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.

I have really bad ankles. I started with flat feet as a child, and things haven’t gotten better in the last 60 years.  Now I wear stiff hiking boots with orthotics you can, literally, drive nails with.  They keep me going.

A fair number of my patients, no matter where I go, come in with foot problems.

Most “ingrown” toenails result from people cutting a corner of the big toenail too short, temporarily relieving the pain but setting themselves up for worse problem when the nail grows out, cutting into the flesh. More than half the time the original problem stems from shoes functionally too small.  I tell people to keep their nails trimmed.  With a flair of showmanship I predict I’ll find a hole worn in their shoe lining from the big toenail, then I tell them to file a bevel into the end of the nail, making it both more flexible and easier to trim when it grows out.

Those with plantar fasciitis start the first step of the day OK, then the pain hits. But it gets better as the day wears on.  At the end of the day, they might sit and relax for 20 minutes but when they stand up they face excruciating pain.  I teach them stretching exercises, encourage them to lose weight, and advise new footwear.

Most WalMarts have a Dr. Scholl’s display; those orthotics (shoe inserts) can be the first step away from the pain. But if they don’t work, I recommend the podiatrist, or, sometimes, the orthotist, a person who does nothing but make orthotics.

The patient gave me permission to say that when I told her to take off her shoes and stand up, her arches sagged to the floor. They looked just like mine.

Then I talked about how I felt the first day I put my feet into the solid inserts. I walked away with a gait 30 years younger, my back straighter.