Fall colors, campfire conversaiton, and American Media

In the north we sat by the fire

I should have used my warmer attire

If discussions of Trump

Turn you into a grump

Just ignore the news that came prior. 

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 50^th 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

Bethany and I food shopped and lunched in Prince George before setting off on a windy, clear, cool day.  Fall comes a lot earlier here in the North than it does in the Midwest, and the autumn foliage colored our drive with bright reds and yellows.

While I drove we held hands and talked about Where Shall We Go Next.  We rank-ordered our choices as Texas, Alaska, Hawaii, and Canada.  Then, in light traffic, Bethany fell asleep.  When I started to yawn I awakened her to keep me company, and, 15 kilometers later, to drive while I napped.

Coming back here felt like coming back home.   We took note of small changes in the buildings and road on the way.

On arrival we found friendly, familiar faces.  We set up our hotel room (really a 1-bedroom apartment) with what we’d brought and what we’d stashed here when we left in May, then we went for a walk in the blustery wind.

We had done a lot in the last 2 ½ days, except sleep.  We napped but I awakened to text one of the permanent docs of my arrival.  He invited me to his back yard for a campfire.

In retrospect, I should have worn my long underwear.

Eight docs sat around an outdoor wood fireplace.  The conversation wandered from medicine to news and back.  Trump.  Tubal pregnancy.  Lead poisoning.  Kavanaugh.  Soy bean prices.  Major trauma.  Beer.  Ultrasound diagnostic advances.  Ontario’s recent elections.  Construction on the road to Prince George.  My summer.  My tribulations with the College, meaning the College of Physicians and Surgeons of British Columbia (CPSBC).  Everyone’s tribulations with the College.  The 90s.  Teletubbies.  More Trump.  More Kavanaugh.

Our host recalled the time when he went out of his way to ignore news and media for two weeks.  He found, at the end, world politics hadn’t gotten better or worse, but he’d been a lot happier.

Then everyone wondered why, as Canadians, they had become so preoccupied with Trump and Kavanaugh.  So I asked what was new in Canadian politics.  Ontario, as it turns out, elected a mini-Trump.

 

 

 

 

 

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Talking to Strangers: art appreciation from a medical journal

In Prince George our plane it did land

As our trip unfolded as planned

Tell me where have you been?

To the hill at Kao Lin?

Just for the learning first hand?

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 50^th 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.

Our plane landed in Prince George on schedule.

When the engine noise stopped, people started to chat.

My area of the US takes pride in being friendly and polite.   I tell them to increase those two parameters by 10% from the most friendly and polite Midwest town on its most friendly and polite day, and you’ll get average Canada.

The friendliness shows in chatting with strangers, something I do a good bit but not as much as Canadian standard. As we stood to deplane, several other passengers asked us our destination.  So of course I gave more details than they probably wanted, but remembering the value of reciprocity I asked similar questions.

One of our fellow travelers just finished 5 months in China. I pulled out some Mandarin conversation openers; she told me it sounded like Cantonese.  So I asked what she’d been doing.

Ceramics.

I nodded sagely and asked if she’d been to Kao Lin Mountain.

Her mouth opened in surprise.

The Chinese perfected ceramics thousands of years ago, and some of the best clay in the empire came from Kao Lin, a texture so fine that the ceramics remain unmatched. The mountain there has provided so much clay that in English, china is synonymous with household ceramics, and kaolin is the scientific name of clay’s active ingredient (the over-the-counter anti-diarrheal Kaopectate, for example, has kaolin and pectin).

Kao Lin figured large in the first globalization of trade, with fully 1/3 of the world’s manufactured goods exported from China.

We agreed that few Westerners have heard of Kao Lin and fewer still know its significance.

I didn’t tell her I would have shared the ignorance if I hadn’t read the art column in Journal of the American Medical Association for decades. (Regretfully, M. Therese Southgate, MD retired, leaving the cover of JAMA bleak and frequently artless.)

She gave me her card. I told her I write a blog, and asked for permission to recount our conversation.

Off to British Columbia, Again

We drove off in the dark and the rain

Between the fields that yield the grain

And got through Immigration

With work permit summation

And set off for Prince George in a plane

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 50^th High School reunion, I just finished a 4-month assignment in northwest Iowa.  Any identifiable patient information has been included with permission

 

I have restless leg syndrome (RLS), and I met with the neurologist the day before my departure for Canada.

He came to Sioux City during my practice-building years. We hunted pheasants together, watched each other’s kids grow into adulthood, and saw the inexorable spread of gray from the temples.

He got through my complicated visit with a unique blend of humor, warmth, and efficiency. He finished 18 hours before our departure for our next adventure.

It takes more than packing to prep for a 3-month absence from home.

I decommissioned the garden while temperatures dropping to the 40s. I threw away papers procrastinated to uselessness.

In the late afternoon we went to our tax accountant to sign our returns, now swollen stacks of frightening thickness.

Friends met us for a going-away Thai dinner. As the sun set we talked about their kids, the soybean harvest, and upcoming plans.

I started packing a little after 9:00PM. It took me about 90 minutes.

I wrote and rolled into bed after 1:00AM. Bethany didn’t stop taking care of business and didn’t come to bed.  She woke me at 5:00AM.

Dropped in the driving rain at the Omaha airport, laid over in Denver for 3 hours, we landed in Vancouver 15 minutes early.

At Immigration, smiling and exhausted, I handed Canadian Border Services a stack of papers detailing my Labor Market Impact Assessment (LMIA), medical exam, med school diploma, residency certificate, approval by College of Physicians and Surgeons of British Columbia (CPSBC) , membership in the College of Family Practice of Canada, family background, previous contract with the Queen, marriage certificate, etc., etc. Bethany handed over a similarly complicated packet requesting a Spousal Open Work Permit.

Then we sat down to wait.

I knew my packet’s weak link, a current but close-dated LMIA, assuring Border Services that no Canadian wanted my job.

Bethany and I held hands and talked about Where Shall We Go Next, because we came emotionally prepared to be sent back from the border.

But about 4:15PM we got our work permits. I snapped a cell phone picture for the government agency that hired me and immediately contacted CPSBC.

We strolled from the international section of the airport to the Canadian section. We had to show our passports 4 times.

We sat in the departure lounge and chatted with polite, friendly Canadians, many awaiting the same plane to Prince George.

 

 

 

 

End of a Canadian month

I have to leave by the first day of May

At least that’s what the border guards say

So my bridges don’t burn

I plan to return

And next time for a 90-day stay

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.

I wrapped up April’s assignment today with a full clinic. I attended 18 patients.

I have written before about propranolol, a remarkable drug whose new uses have vastly eclipsed the original indication, high blood pressure. I prescribe it for stage fright, social anxiety, ADHD, buck fever, overactive blushing, and migraine.  Today two of my patients received prescriptions for propranolol; one has taken it for years for stuttering, and it works well (I received permission to write a good deal more than I have).

Seven patients’ medical problems come from alcoholism. Treatment depends on willingness to change, and that trait today ran the spectrum from having quit to wanting to die drunk and soon.

Two patients suffer from bipolar illness but came in for something else.

Three needed notes approving them back to work. Two asked me to write slips containing little truth, and I declined.

Two patients have puzzling clinical pictures. I don’t have to know everything, all I need to know is how to find someone who knows more than me, and I sent both patients to specialists.

The clinic manager plans to make scheduling changes, staggering start times for the docs and the Nurse Practitioner, running clinic through the lunch hour, and perhaps starting night hours. Details have to be worked out, but, as one of my colleagues observed, and gave me permission to quote, 100% of the ideas you didn’t try will fail.

I walked back to the room at lunch, ate some very tasty leftovers, and did some last-minute packing.

Back at the clinic I tried to catch up on documentation while I cared for patients, and reviewed lab, x-rays, and consults. Outside, the fine clear day clouded over, and the snow piles continued to melt.

Patients expressed dismay when I told them that Immigration decreed that to keep a relationship good enough to return I would have to leave on May 1. Actually I said that Immigration was kicking me out, but they’d probably let me come back in October.

In the long northern afternoon, Bethany and I loaded the car and headed to Prince George. Just outside of town we saw three mule deer grazing by the side of the road, and a hundred kilometers further on, far off at the edge of a flat marshland, we saw a cow moose with her calf.

Canadian spring

We now find ourselves in the spring

We can see what the weather will bring

With the sun’s warming glow

Melting the snow

Sending geese north on the wing.

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.

This part of British Columbia sits further north than the tail of Alaska. At this season, the sun rises early and sets late.  Temperatures at night drop barely below freezing, while during the day the dirty mountains of snow, accumulated from a winter of snow clearing  melt.

Two weeks ago despite temperatures above 0 Centigrade (32F) we had white-out grade snow falls that melted so fast they didn’t whiten the pavement.

When I picked Bethany up 10 days ago, we saw ducks and geese swimming in the melt at the edge of the lake ice.

We have cool, sunny days too warm for the lightest jacket I brought. I walked to work in shirt sleeves this week. Bicyclists come out in force on Sundays, about half wear shorts.

Trucks tow a lot of trailers here, and this week snow machines gave way to boats.

Last week I saw the first sunburn of the year, though from damage done much further south. I have started to sunscreen my face in the mornings.

This week I had a spirited discussion about how often moose collide with vehicles. I also filled out Workman’s Comp Insurance forms in cases so unusual and so uniquely Canadian that revealing details would reveal the patient.  But such great stories! No one would believe the truth if I wrote it as fiction.

I was seated at the nurse’s station on the hospital side when a Mounty came in. I greeted him with all the friendliness of a rural Midwesterner transposed to rural Canada.  After pleasantries he held up a sheet of paper and the nurse directed him to Medical Records.

Several times this last week I told patients not to expect medical improvement until they stopped alcohol/marijuana/meth. Each one needed follow-up and each one asked to do so with me.  Every single one expressed disappointment when I said that Immigration would arrest me if I didn’t leave the country on May 1.  Either the patients liked my approach or they’re extremely polite; the two are not mutually exclusive.

One evening as I finished documentation I noted with alarm that I had not seen the last patient on my list. I found him in the exam room, Canadian polite mixed with understandable anger.  I said, “This is my fault, no one else’s.  Do not blame the staff.  If you complain, complain about me.”  I called a couple of days later to apologize again.

 

 

Shared delusions and eggs over easy

It’s called a folie a deux

When delusions are shared by two

Or possibly more

But who’s keeping score?

When our breakfast we’re trying to chew.

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.

During my work time here, I get housed in a hotel a short kilometer walk from the clinic. The accommodations comprise what amounts to a 1 bedroom apartment.  We have a small kitchen, a stove with a real oven, and a decent-sized refrigerator.  The bedroom has a door that closes.

But the room also comes with a continental breakfast at a nearby restaurant. You can’t call the meal fancy, but we can get eggs cooked to order.

The hotel business runs light at this time of year, a far cry from last summer when one could hear loud conversations around the building all night. We haven’t had to share the breakfast room since before Bethany got here.

Today I greeted another breakfast guest as we walked in; he promptly said, “You look like an old professor.”

“I like to teach,” I said, “but that’s not what pays the bills.”

We nodded at another patron as we put bread in the toaster.

The owner by now starts my two eggs, over easy, as soon as I walk in the door.

As we sat down, the two other customers started an animated conversation, in volumes large enough to fall far from the bounds of what could be called a restaurant voice. In short order, I recognized the linguistic tells of mania (rapid speech, flight of ideas, grandiosity) for one and schizophrenia (in plain English, he didn’t make tracks) in the other.  But they found each other’s conversation fascinating.

We didn’t interrupt or join in. We just listened.

The manic customer very quickly convinced the schizophrenic customer.

You can find bipolar disease at the same frequency in every population in the world. My opinion runs something like this: in the manic state the bipolar functions as an irresistible leader with an uncontrollable libido.  He or she can convince the group to go places where, literally, no man has gone before.  On arrival, that person leaves a disproportionately high number of offspring with the same propensities.

At the restaurant, I listened to the founding of a folie a deux. Where insanity usually runs a solo game, a folie a deux relies on a two person delusional system.  Such cases notoriously resist treatment.

But I did not serve as their physician and thus cannot claim them as patients. They spoke loudly in a public place.  And, after all, such a scene almost certainly played out in more than one venue today.

So I can write about it. Rules of confidentiality do not apply.

 

Corneal numbness and a schizophrenic hitchhiker

You might think cocaine’s a prize

The truth is it’s a thing I despise

You’ll hallucinate bugs

On that class of drugs

And you might try to pry out your eyes.

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.

Before and after clinic, and between patients, the docs in this clinic congregate in an office with 6 chairs and computer stations.   You can find quieter, more efficient places to dictate or keyboard or research under this roof, but, still, docs who have work stations elsewhere come in frequently during the day.

Earlier this week, at the beginning of the day, I brought up the subject of eye pathology. In the course of a referral to an ophthalmologist, I learned that cocaine abuse can numb the cornea, and I spoke the new knowledge to my colleagues.  The information amazed them just as it had amazed me.  And then the clinical stories started.

Cocaine and other drugs like unto its kind, such as meth, speed, or crank induce hallucinations and delusions. Paranoia, of course, runs rampant, but so does the sensation of insects or foreign bodies in various parts of the body. Most people who have known tweekers know that they pick at themselves, giving rise to “speed sores.”  They also pull out hair (trichotillomania).  But then we all listened, rapt, while one physician talked about a heavy cocaine user who had used a screwdriver to try to remove a non-existent contact lens.  We all shuddered, shook our heads, and muttered, “drugs.”

Canada stands on the verge of national legalization of marijuana, and I see no good coming from it.

+-+-+-

I got called to ER for 2 patients in the early morning hours. The second patient recognized and greeted me by name.  “Were you gone for a while?” she asked.

Within 24 hours two more patients made the same mistake: they thought I had permanent status rather than temporary. The place is starting to feel like home.

+-+-+-

I picked Bethany up at the airport in Prince George Friday evening. We stayed the night, went grocery shopping at Costco on Saturday, and got on the highway.  Just outside of town, we picked up a hitchhiker.

Last summer we picked up a couple from Europe, working their way across Canada for a year.

This time, at about the same place, I pulled over for a middle-aged man with backpacking gear.  We chatted as the kilometers slipped by.

Residing in some of the more violent, drug-ridden, lower-rent sections of East Vancouver, he’d lost several bicycles and his wallet to theft. In years past, he’d driven motor vehicles, from garbage trucks to RVs, from the Midwest US to Anchorage, Alaska.

Then he started to talk about how dizzy he got when surrounded by too much technology, especially wi-fi.

He planned to take the Dempster Highway north through the Yukon to Inuvik, the capital of Nunavut, the Canadian Territory that belonging to the Inuit.   He wanted to work along the way.

As the now familiar highway slipped past, I listened to his delusions coming with increasing frequency, without contradicting.

I strongly suspect untreated schizophrenia.  He can function in society, even if he functions marginally. He can hold a job, even if not for very long, and he has chosen a path that leads him away from high availability of drugs.

We dropped him off in an area with decent traffic flow. I looked up the Dempster Highway when we got back to town.  I hope he times his river crossings right, otherwise he’ll be waiting a month for a ferry or an ice bridge.

 

 

Where FedEx doesn’t go

My summer plans just fell through

There’s a thing or two I should do

It takes hours and ages

To fill out the pages

To serve at a clinic that’s new.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

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

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

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

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

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

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

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

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

 

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

Geography knowledge is rare

And even those doctors who care

Have recommendations

That get emendations

With exclamations of “WHERE??!!”

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

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

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

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

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

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

I sent one patient by ambulance to Prince George.

I called the Mounties once.

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

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

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

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

The last week of the year

The Canadians were boxing that day

The 26^th is a time that they play

But I took the call

Which was not rushed at all

But was long. What can I say?

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.

Much has happened in the last week.

Sunday: I don’t celebrate Christmas, I support my colleagues who do and go out of my way to take call on 12/24 and 12/25. But this year, I had to compete with two colleagues who don’t celebrate either, and for the 3^rd time since the 70’s I didn’t work the holiday.  Bethany and I went cross country skiing.

Monday: We rented waxless skis from one of the hospital staff. I wore most of my clothing, including seal skin mittens and a beaver fur hat purchased in Alaska.

Bethany and I hadn’t cross-country skied together so far this century. The last time I went out on skis, waxless skis had just come out. I still ran then, compulsively, and I had some flexibility left, and my hair and beard had yet to turn the color of snow.

We went out for 3 kilometers, not far as cross-country skiing goes. I didn’t fall till the very last, and had to clip out of my skis in order to stand up.

Tuesday: I celebrated Boxing Day for the first time.  One of my Canadian patients explained the holiday:  “You stay in your pajamas all day and eat left overs and play with your toys.”  Of course I thought that kind of celebration laudable and wondered why it would only come once a year.   But I had volunteered for call that day, giving it to the Canadians who celebrate the holiday, and who couldn’t imagine that an entire country wouldn’t.  Steady patient flow, about one per hour, let me pay enough attention to each patient without rushing.  But it kept up till just shy of midnight.

Wednesday: ER patient at 3:00AM, requiring lots of ER care. In the middle, I returned to the room, showered, and changed. Back at the hospital an hour before dawn, the sky brightening in the east.  I faced the coldest temperature of the year thus far, -25 Celsius (-18Fahrenheit).  The new snow squeaked in protest as I stepped.  I worked the walk-in clinic, despite assurances I could take the morning off after a hard call.  I lunched back at the hotel, napped marvelously, and walked back to finish the afternoon.  I didn’t want to drive; scraping car windows inside and out takes more time. I did, however, drink a cup of coffee.

Thursday: after caffeine ruined a good night’s sleep I returned to clinic early to finish the inevitable odds and ends that come at assignment’s termination.   Unable to enter the dictation system for a discharge summary, I sighed, sent an email, and moved on.  I cleaned out my electronic queues of lab and x-ray reports, and consultations. I had 500 items, of which two made me exclaim out loud, not because I had been wrong, but because I had been right.

Friday: We scraped the car windows, put the heat on full blast, and packed.  At the clinic we said good byes and snapped pictures.  On the drive to Prince George any outside temp less than -19C iced our breath inside the glass.

Saturday: Getting to the airport 30 minutes before boarding gave us plenty of leisure.  I pointed out my multi-tool to the airport security personnel.  She told me Canada approves blades less than 5 cm, but I would lose it in the States.  It doesn’t have a blade but I didn’t argue.  We left in the dark and the snow, and 18 hours later landed in the dark and the snow in Sioux City (and temperatures of -26F/-33Celsius, even colder than Canada) after two long layovers separating three boring flights.  The best kind.