Archive for the ‘Keosauqua’ Category

After thirty years, a case of Reiter’s syndrome, and my last Keosauqua patient shatters my complacence.

December 30, 2010

When I stopped to check out the heart,

The rhythm gave me a start.

     It was going too fast,

     And that patient, the last,

Went out on the ambulance cart.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks off, I’m having adventures, working, and visiting friends and relatives.  I’ve been on assignment in Keosauqua, in southeast Iowa.

Today I finished my last clinical day in Keosauqua.  The first patient of the day and the last patient of the day each gave their permission to write the information below.

Reiter’s Syndrome includes the triad of conjunctivitis (inflammation of the eye membranes), urethritis (inflammation of the lower urinary tract), and synovitis (joint inflammation).  Such a constellation signals the body’s abrupt inappropriate reaction to an infection; while attacking germs, the defense mechanisms start to attack the person’s own tissues. 

Separately, each of these three items comes as common as rain, and for the last thirty years I’ve asked each patient with one of them about the other two.  I also ask about fever and rash.  The interview sequence qualified long ago as low-yield, but I persisted for sake of thoroughness, and, later, from habit. 

Over the years, my interview technique has evolved.  In the beginning I listen, later on I ask focused questions.  Today, when I said to the patient, “Tell me more,” three sentences in quick succession revealed knee pain, discharge from the eye, and discharge from the penis.

For the first time, ever, today I made the diagnosis of Reiter’s Syndrome.  I started the proper lab investigation and turned the case over to a colleague.

For those interested in medical history, Christopher Columbus suffered from Reiter’s Syndrome on his last voyage.

The last patient of the day came in with a routine complaint of cough, also a frequent problem in temperate climates in the winter.  Such symptoms have been going around Van Buren County during my short stay here, and I anticipated ending my tenure routinely.

The human condition tends towards complacence.  We tend to “know” we’ll find a normal cardiac exam singing “lub-dub, lub-dub.”  If those sounds don’t come through the stethoscope, the brain tends to want to make the perceived sound fit into the expected sound.

Today it didn’t.  “Breathe normally,” I told the patient, and tried to hear the heart sounds over the abnormal breath sounds.  Unsuccessful, I said, “Hold your breath.”  The first and second heart sounds refused to distinguish themselves; the first kept shifting in timing and character.  And the rate came way too fast.

I took my stethoscope off and checked the pulse, which came through nice and regular.  I listened to the heart again.  The chaotic rhythm pounded irregularly irregular. 

The reassurance I sought from the electrocardiogram fled before my eyes.  Yet the patient had no heart symptoms at all; no chest pain or sensation of his heart racing.

I grabbed one of my colleagues and showed him the strip.  In short order we had sent the patient off in an ambulance.

We agreed that the weird stuff is out there.

Muzzleloading for deer. Caution: hunting content longer than usual.

December 29, 2010

Before Christmas, I said with good cheer,

I’d like to go hunting some deer.

    It’s not a trifle

    With a front-stuffer rifle,

 It’s kinder than a car or a spear.

I am sitting in a deer blind with Jason, a man who knows the county and knows deer, and above all, knows the farm we’re hunting, across the Des Moines River from Keosauqua.

This afternoon we watch from a blind inside the tree line, a hundred yards from the river.  In front of us stretch oats and soybeans, four acres of buffet for deer.  Two hundred yards to our left a creek runs into the river; during the floods of spring a fifth of the soybeans got flooded out.

The blind itself has a six-year tenure in this location.  Stays have parted company with hubs; locally grown wood verticals and cross-braces keep the structure upright and useable.   It maintains a footprint five feet by five feet, the roof doesn’t quite permit me to stand.  The door zipper works well, the window zippers run a spectrum of functionality.

We slipped in silently before two in the afternoon, whispering.  The deer will probably come, he said, through the timber on our left, to the fence right in front of us.  Or they will come up from the timber between us and the river. You watch left, and I’ll watch right.

Through the afternoon we listened to six dozen geese on the far bank and watched eagles cruise glide over the water.  A light breeze blew from the river.

A piliated woodpecker caused a frightful racket in back of the blind, then perched two feet in front of us, peering through the window till I smiled.

From behind us I heard feet moving in leaves and my heart raced till I discerned, not the measured four steps of a deer but the chaotic hop-hop of a squirrel. 

Shortly after four Jason nudges me and whispers that he sees two, maybe one deer on the right, come up from the river just as he’d predicted.  I strain my eyes in the cloudy pre-dusk, then I can see her back about the level of the oats; her head down while she eats. 

Too far to shoot, we agree.  He tells me to watch as the deer make their way to our left, the shot will be easy. 

I resist the urge to stare, but my pulse quickens and my senses waken.

After ten minutes he nudges me to tell me I could have a shot.  I slowly ease my Savage .50 caliber, loaded with a 295 grain solid copper Power Belt over 47 grains of 5744 from the corner and poke the barrel out the window. 

In the scope the scene sixty yards away jumps to life.  The deer in front has two small dark circles on his forehead.  “He’s a button buck, should I take him?” I whisper.

“No, let him be, he’ll keep coming back,” he says.

Later, “That second one there, you’ve got a good shot.”

But in the scope I can see the ears of another deer behind the doe in front.

“Not a shot,” I say, “I could wound one on the off side.”

A few minutes more, then I say, “OK, she’s stepped forward.  I’ve got a clear shot.  The one in front.”

“Go ahead and take her,” he whispers.

I slip the safety off.  My heart pounds so loud I am sure the deer will hear me. I steady my left elbow on my left knee and I slow my breathing.  I go through my litany of questions:  Is this a good shot?  Can I make this shot?  What is on the other side of the target?

Breathe, relax, aim, stop, squeeze; the rifle kicks in my hands.  “I don’t see her,” I said.

“You got her,” he says, slaps my shoulder and laughs,“She’s down,” as the dozen suddenly obvious deer flee towards the cover on our right.

“Should I reload?” I ask. 

“No, man, you got her, she’s down.  Where were you aiming?”

“Right where the neck meets the spine,” I say, as he zips the door to the blind open.

We slap high fives.

We walk through the gate into the oats.  I shiver with intensity. 

The doe lies on her left side in the soybeans, the bloodless bullet wound showing on the front of her shoulder.  We slap unrestrained high-fives again.

And she is a very large doe.  I slip off my blaze orange coat and I don latex gloves, breaking out my field dressing hardware while Jason calls his dad, Doug, to bring a four-wheeler.

With my doe in the soybeans. Note muzzleloader across my lap.

I use a good but imperfect tool called a Buck Buster.  I have ideas for improvements: change the angle of the handle, put in a groove here and a curve there, shorten and lighten the whole assemblage, but for the time being I have the best tool for the job in my hand. 

Jason watches me work.  “You look like you might have done this before.”

“Yeah, a couple dozen times.  If it looks like I’m going too slow you just say, ‘No lawyers,’ and I’ll speed up.”  While I work I tell the story of painstakingly gutting one of my first antelope, and after forty-five minutes one of the observers said, “You know doc, I don’t think he’s going to recover, and if he does you’re going to have a bigger problem on your hands than you got now.”

The deer’s chest cavity, full of blood, shows the course of the bullet.  Hitting the spine, it exploded and fragments severed the aorta.  She died instantaneously, and probably never heard the shot that killed her.
Doug comes up on his four-wheeler.  By the time the field dressing is done, the day has passed from dusk to overcast night.  Jason and I haul the doe up and pour the blood out of her body cavity.

Then they are gone to pick up Jason’s four-wheeler with its trailer, and I am alone with the deer.  I talk to her, and I thank her for coming to feed me and my family. I peel off the latex gloves to find that both sides have leaked deer blood onto my hands.  I wipe my hands on weeds as best I can, and I put my coat back on after the blood dries.  I call my brother to tell him the news, and hang up as the two sets of headlights approach.

When Jason and I lift her into the trailer, I realize how much bigger this deer is than 80% of the bucks I’ve shot.  Even without her thirty pounds of innards she weighs close to two hundred pounds.

Jason goes ahead and I ride behind Doug.

While the exhilaration of a good shot and clean kill runs through me, I remember other hunts; Cuba, Arkansas, and Louisiana; doves, ducks, quail, geese, pheasants; elk in New Mexico; warm weather, cold weather, wind, snow, rain and glorious sunsets.

Two miles up the hill, Doug, Jason and I prepare the doe for skinning by making certain cuts before elevating her on the hoist.  We work in Doug’s machine shed.  He built it with an eighteen-foot ceiling instead of fourteen-foot, and reinforced key places so that raising deer on his hoist would not be a problem.  With the vigor of youth, Jason helps me skin and between the two of us, the job finishes in minutes. 

With the hide gone I look for the exit wound and I do not find it.  I can clearly see where the projectile shattered the spine, but my probing finger doesn’t find a bullet.

I have never shot a deer before and not found an exit wound.

Jason takes off down the hill and I start working on the deer, in a process called quartering.  I remove the forequarters, tenderloins, then the backstraps, then I trim meat from the carcass and the neck. 

I find two and a half inches of fat covering her rump.

Doug complements me on how clean my work looks.  I remark that it used to be a lot better but it used to take me all night.  Doug shows me how to use pruning loppers to detach the bony hocks, and I file the tip away for future use.  The cleanest meat, which doesn’t need further editing or washing, goes into a cooler with freezer packs.  The hind quarters, which always carry a taint of blood, go into garbage sacks.  Miscellaneous trim goes in with the back straps.  I point out to Doug the four ounces of meat along the sacrum, and I highly recommend it and I think about cooking it up tonight.

Before six-thirty the useable meat has been detached from the axial skeleton.  As I put the two coolers into the car I estimate one weighs sixty-five pounds and the other weighs fifty-five pounds. 

Driving the five minutes back to the duplex, two does try to wreak suicidal revenge on me by running right in front of the car. 

No one can deny that the country has too many whitetail deer.  This county shelters more deer than any other county in Iowa, and the population continues to grow yearly despite liberal hunting season and limits.  My permit allowed me to take antlerless deer only.

At the duplex I shake flour into a plastic container, add the only spice I have at hand, Mrs. Dash’s, and heat a generous amount of oil in a fry pan.  I dredge the thumb-sized chunks in the spiced flour, shaking off the surplus, and sear the meat till brown on each side.  I sit down with a piece of bread and I eat and I relive the eperience.

I change out of my clothes and drive to the hospital to make late rounds on a mother with a new baby.  Contrast is still the essence of meaning.

Back at the duplex I start the process of removing flesh from bone and sealing the meat into cryovac bags.  I decide to name the deer Sally.

I come across a bullet fragment in the backstrap; had this been a beef animal, the piece of metal would have been in the ribeye.

Muzzleloader bullet fragment extracted from the backstrap of my deer; paperclip shown for size comparison

 

I rarely find bullet fragments in the animals I’ve shot.

Hollywood misrepresents firearms; whole rifle bullets do not lodge in anything weighing less than a ton, and can never be used for ballistics testing.

I cut, package and freeze meat till midnight, and I start the clean-up process. 

Packages I have had cooling on the back porch come in to beds of foil in the refrigerator.  Knives get washed and sharpened.  I realize I will work with a paucity of cutlery.

Buzzed from the hunt, I can sleep no more than three hours before I waken to cut some more.   In a rhythm learned through years, over the next four days I place cryovac bags in the freezer labeled chuck, backstrap, tenderloin, best trim, trim for stew, top round, sliced round for jerky, and chunked shank for stew. 

I work in two hour segments, washing the setup thoroughly and sharpening knives before moving on to the next anatomic area.  Every two hours I take the best looking small pieces at hand, dredge them in spiced flour, and fry them.  Names of muscle groups, like supraspinatus or tibialis anterior, come to my mind as I work and as I eat.  I relive the moment over and over, from the time I first saw her to the time I pulled the trigger.

Call takes up all of Friday night and Saturday.

Monday afternoon the last package goes into the freezer before I go to work.  I clean the counters and I start rinsing the refrigerator shelves. 

The euphoria of a good shot well made courses through my veins while I work.

In a small town, word gets around.  People drop into my office and ask me how I like the deer hunting here.  (I like it a lot.)

In retrospect, I shouldn’t have bought two anterless tags; I had plenty of work from one deer.

Hepatitis, joint pain, and missing the solution to the mystery

December 28, 2010

To what disease do the symptoms belong,

When dark urine lacks odor so strong?

     I made a few points

     When I asked about joints

But the truth is I’d rather be wrong.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks away, I’m having adventures working in new places and visiting friends and relatives.  Right now I’m staffing a clinic in Keosauqua in southeast Iowa.

My month in Keosauqua draws to a close tomorrow.

A patient (who gave me permission to write this information) came in today with a puzzling constellation of symptoms for two weeks: fatigue, malaise, chills and sweats, joint pain, morning stiffness, abdominal pain, vomiting and diarrhea.   The fingers on the right hand were swollen, visibly larger than those of the left hand, and index and middle fingers had swelling of the knuckle joint close to the hand.  I found other abnormal items on the physical exam, my fingers gliding over tiny, painful lymph nodes at the inside of the upper arm, just above the elbow.

On the basis of an impulse whose source I do not know, I asked the patientiof the color of stools had lightened and that of the urine had darkened.  They had.

At the end of the visit I said, “You want me to be wrong about everything I’m thinking of because the best diagnosis we can hope for is infectious mononucleosis.  That’s the best one.  You don’t want rheumatoid arthritis, Lyme disease, or hepatitis, or any of the worst things that I can think of.  And I suppose it’s possible that it’s work related.  We’ll have to see.”

Not widely known, but the rheumatologists make the diagnosis of hepatitis B more often than the gastroenterologists. Early in the course of the disease, any hepatitis can look like rheumatoid arthritis.  Patients can, and do, have severe joint pains without any abnormality of the liver function tests. 

Hepatitis B should be prevented by immunizations administered in infancy.  However, some parents choose against immunization (which I find foolish) and a very few people will not make antibodies in response to the vaccine.

Hepatitis C can cause similar joint pains, but usually doesn’t.  Mostly it causes an overall sensation of fatigue, less often the classic signs of hepatitis, with jaundice and swollen liver.

In medical school, hepatitis came in the classifications of infectious and serum.  By the time I finished residency, infectious hepatitis bore the name A and serum hepatitis was called B.  The third one, called non-A non-B hepatitis, eventually found the name C.  Ten years ago, hepatitis C mostly smoldered along and every once in a while resulted in liver cancer.   Five years ago we had a cure rate of 10% and now we have a cure rate better than 50%, and improving.

In the end, the patient’s diagnosis will come from lab work, but by the time the results come back I will have moved on.  I will not witness the denouement, the answer to the mystery.

At the end of the afternoon, I introduced the patient to one of the other docs here and made arrangements for follow-up.

The patient lives in a world, a social context with relatives, friends, and a job or two.  I will miss out on seeing how the disease affects the person and the world around them.

I will wonder.

After a bad Christmas on call.

December 27, 2010

While the snow outside piled deep,

Inside sometimes I’d sleep.

      But through the thin and the thick

     The people came sick,

To laugh, perchance, then, to weep. 

If you want to make a psychotic rat, you put EEG (brain wave) electrodes on it, wait till it gets to rapid eye movement (REM, or dream) sleep, and wake it up by ringing a bell. 

Christmas call did not go well.  I felt like a rat in the psycho experiment.

With reasonable volume and intensity the pace stayed steady through the night, and every time I got to REM sleep the phone went off.  Ripped from very pleasant dreams, time after time, I drove through the bracing cold the half mile to the hospital.  With one exception, the patients were sick human beings who just wanted to get better, and who had come at the right time.  I can look for no one to complain or whine to; my job snatched me from sleep’s warm and healing embrace so many times that I gave up and slept in the call room at the hospital.

Most hospitals have one place for doctors to sleep, and another for doctors waiting for a baby to deliver.  Van Buren County Hospital has both; the better room, called the ‘Doctors’ dictation room,’ near the inpatient nurses’ station, has a refrigerator, sink, and shower.  Nicer by a  long shot than the studio apartment I lived in my senior year of medical school, the mattress there provides the foundation for a good night’s sleep.  I just didn’t spend enough time on it.

My fellow human beings in distress kept seeking my training and experience so that they could feel better.  I can write about things in general without writing about people in particular.

For two of the pediatric patients I worried more about the parents than about the kid.  For another patient, inherent stubbornness provided more of a challenge than the diagnosis.

I had to dialogue with the sheriff about another patient.  After I certified neither a danger to self nor others, the sheriff made sure the person got to the other side of the county line and notified the next agency.

Three quarters of the work came from the destructive influence tobacco smoke has on human tissue. 

One quarter of the time apparent alcoholism served as smokescreen for the real problem. 

Our CT machine stopped working, won’t be functional till tomorrow, and I had to send a patient up the road to Fairfield. 

When a person comes in with press of speech (talking fast), flight of ideas (giving voice to racing thoughts), and tangential associations (can’t keep track of what they’re talking about), only four diagnoses come to mind: hyperthyroid, cocaine use, meth use, and mania.  But that person hadn’t come to see me, rather to accompany the patient.  I made the recommendation to check with their habitual doctor and ask for a thyroid test.

Putting pressure on a wound stops the bleeding almost always; elevating the bleeding part above the level of the heart speeds the process.

Shortly after a human being turns into a man, stupidity takes over and only slowly releases its grasp, if ever.    

The accumulated sleep deficit has piled up since Thursday.  My appetite control has evaporated; carbohydrates lurk near me at their own risk.  (See my post entitled Rage, Hunger, Lust, and Sleep.)

I’ve fallen asleep twice at the keyboard since I started this post.  Good-night.

Application of medical first principles on a Tuesday in Keosauqua

December 21, 2010

Why do doctors go gray?

Is it all work and no play?

     Life can be a ball,

     Though you’re working on call,

Just don’t give in to dismay.

When I’m on call, nights or weekends, I get a lot of calls from people who have self-diagnosed an antibiotic deficiency and want a prescription called in.  Pain with urination, sore throat, and cough comprise the most frequent complaints.

I would like to say I don’t ever yield to the request, but on rare occasions I do.  I weigh the risk to the patient of treatment with an exam versus the risk of treatment without an exam.  Most of the time I’m pretty rigid, but flexibility sets in during extreme weather.  Last year a blizzard descended on Sioux City when I had Christmas weekend on call.  On a day when it took three hours to get from my garage to the street, I said “Yes” a lot.

Most sore throats do not benefit from penicillin.  Most pain with urination is not urinary tract infection.  Most earaches do not come from ear infections.

Today I saw four patients with painful urination, abrupt onset, accompanied by blood in the urine.  One had a urine infection.

I work very little to write out a prescription for three days of antibiotics; I work a great deal more explaining why the patient shouldn’t take antibiotics.

Of the last nine patients with pain in the ear, one had an actual ear infection.

Three other patients, all smokers with emphysema, came in short of breath today; they all left with prescriptions for antibiotics and inhalers.  One got a prescription for prednisone (a steroid).

On six occasions today I added up the costs of peoples’ bad habits.  “OK,” I’d say, “How much are you paying a pack for Marlboros/a bottle for Mountain Dew/a cup of coffee/a pack of generics/a case of beer?”  I got out my calculator and said, “Dang!  Eight hundred dollars/twelve hundred dollars/nine thousand dollars a year!  They must pay you well!  I’m a doctor and I couldn’t afford that.”

People who work with livestock in general and horses in particular don’t complain much, and if they do, I’d better listen.  I applied that principle twice today.

Three folks with mental health histories were in today; their complex medical problems took time.  I considered the principle that craziness doesn’t protect from physical illness.  I have a lot of lab results pending.

Four patients let drop the fact that a close relative had died in the last six months.  I listened and I sympathized.  I remembered the ten months after my mother died, when penicillin injections kept me going during a succession of eleven culture-proven strep throats.

Depressed patients get sick, and sick patients get depressed.

Art and Architecture in rural Iowa: Bethany and I do American Gothic

December 19, 2010

There once was an artist, Grant Wood,

Who did that best that he could

    A house he did paint,

    With a couple so quaint

And the parodies all turn out good.

Bethany drove six hours from Sioux City this weekend, and yesterday I took her for a walk around town.  We heard a skittering cry from a large bird gliding above the Des Moines River.  We stood still to watch, it circled and wheeled and leisurely came to us, twenty feet up, a bald eagle, with snow-white head and tail.

Then we heard the helicopter. 

The sound of a helicopter in a small town usually bodes ill as the harbinger of significant injury or illness.  We strode up the hill to the hospital.

My colleague had the situation well under control.

We walked past the Manning Hotel, an historic structure dating to the era when goods moved by riverboat and horse. 

The Manning Hotel, Keosauqua, Iowa, on the banks of Des Moines River

The bridge over the Des Moines River here carries partitions for three types of traffic: the east lane for pedestrians, the center lanes for cars, and the west lane for horse-and-buggy (the Amish regularly cross the bridge).

This part of Iowa has wonderful architecture, with colonnaded porticoes and functional verandas on many houses.  Victorian-style gingerbread sits next to single- and double-wide trailers.  In Birmingham we found a trailer with a colonnaded portico.

Trailer with collonaded portico

On the way there we saw the sign proclaiming AMERICAN GOTHIC HOUSE 18 MILES.  Today, we made the drive.

Grant Wood’s painting, American Gothic, ranks second only to the Mona Lisa for number of parodies.  The house, I have been told, is the second most recognizable house in the country, after the White House.

That house still stands at the edge of Eldon, Iowa, less than a half hour from Keosauqua. 

The town itself looks like many other small towns but for the beautiful architecture.

The American Gothic House reminded us of the size of our first house in Casper, Wyoming, with less than nine hundred square feet.  The American Gothic House Center, on the other hand, stood large in the neighborhood, with a CLOSED sign in the front door.

Bethany at the American Gothic House Center. Eldon, Iowa. December 2010

Of course we had to make our own parody of Grant Wood’s famous painting, which rendered difficult the task of trying to look dour.  I had not a pitchfork nor a shovel to hold, Bethany observed, as she shivered and tried not to crack a smile. 

Steve and Bethany in front of the American Gothic house, Eldon, Iowa, December 19 2010

With the camera screwed onto the tripod, the self-timer did its job as hypothermia started to set in.

The famous house now shares the corner with a single-wide trailer; functioning agricultural buildings stand between it and the corn fields.  A trendy compact car nestles in back.

The American Gothic House and Mini-Cooper, Eldon, Iowa, Dec 19 2010

The recognizable icon stands but the times, as always, change.

The knife slipped gutting a deer and the wound won’t stop bleeding.

December 18, 2010

A mistake while gutting a deer

Caused the blood to appear

     Despite all my reading

    It’s hard to stop bleeding

Surgery’s not my career

The patient involved gave me permission to write about him.

His knife slipped while he field dressed the doe he shot Friday morning, the blade went about and inch and a half (3 cm) into his right thigh. He pulled it out, and it bled vigorously and he came to the hospital for stitches.

The Nurse Practitioner on duty in the ER tried local pressure to stop the bleeding, which didn’t work.  She asked me to step away from the clinic to give her a hand.

The wound itself, about an inch long, filled up with blood as I watched it. I tried a pressure dressing with 4×4’s and an ace bandage for 30 minutes.

Dark red blood continued to well up.

I am not a surgeon, and every time I thought I could be one I witnessed horrendous complications in the hands of competent men and women, who pulled the chestnuts from the fire every time, even if they sweated to do so. I gave up decades ago on my fantasies of surgical practice. I do OK on skin, but I don’t like to go deeper than that. 

I know what to do when I don’t know: call someone who knows more.  I phoned the hospital of the patient’s choice and asked for the trauma surgeon on call.  Of course I my communication got shunted to the emergency doctor.

The conversation passed between us with one good idea exchanged.  “I’d just elevate it and put ice on.”

Elevate?  Sure, a great idea: use gravity as an ally.  Ice? I just took the Advanced Trauma Live Support (ATLS) course; one of the scenarios had to do with a young patient bleeding profusely from a thigh wound.  Applying pressure slows bleeding, it doesn’t always stop it, neither does ice, and I didn’t want to send a bleeding patient home.

The patient’s cut, outside my comfort zone for treatment, didn’t justify transporting the patient to a surgeon.

I gathered my breath and decided that whatever else I can or can’t do, I could anesthetize the wound and irrigate it.

I used five millilitres of 1% Lidocaine with epinephrine, a medication that constricts blood vessels and slows bleeding.  I injected as I advanced the 1 1/2 inch needle to the hub.  When the red river slowed to a trickle I could see a significant bleeder, right at the skin edge.  I clamped it with a hemostat and tied it off with 3-0 chromic, and the bleeding stopped. 

By then I’d spoken with a real surgeon, who advised against closing a wound containing contaminated by deer fat and clothing fibers.

I relieved the patient when I announced I wouldn’t be sending him by ambulance to a different ER and a surgeon.

But we talked a lot about deer hunting.

Santa at the library. Warning: humorous content

December 16, 2010

The problems of running a sleigh!

With six months of night and of day,

     To deliver a toy

     Or in Hawaii, some poi,

I don’t send the elves out to play.

Synopsis:  I’m a family practitioner from Sioux City, Iowa, transitioning my career.  While my one-year non-compete clause ticks out I’m doing locum tenens work, and having adventures.  Currently I’m in southeast Iowa.  I played Santa this week, and my sense of humor broke loose.

I put on a red suit and went to the Keosauqua Public Library as Santa.

I talked with one of the librarians after the rush of kids slowed down.

He commented he hadn’t seen my sleigh.

“It’s second shotgun season,” I said.  “You know, I was crossing the Van Buren County line just before dark, keeping the sleigh low along the river over there by Bonaparte, I heard a shot and I’m darned if a 12-gauge slug didn’t crease Donner’s left hind hoof.  Scared the heck out of me.  I took her up about two hundred feet, swung south there and crossed into Missouri, set her down in an alfalfa field to check out the damage, wouldn’t you know up drove a guy, a doc, in a ’98 Toyota Avalon.  We yacked a little bit, he said he’d do what he could for Donner even if he weren’t a vet, and let me drive his car into town.  That’s why I came in late.”

The librarian nodded.

“Heck of a deal,” I said, “You know at the North Pole we get six months of daylight to make all those toys but when the sun goes down on September 22, it goes down and it stays down, and I’ll tell you what, it gets dark.  And we just keep working through the winter solstice, it gets to be December 24th and I head south, I cover a lot of ground.  You know, I remember back winter of ’93 when we had all that snow, I was fixing to land on the roof of a farmhouse outside of Effingham, Illinois.  Well, they hadn’t shoveled the snow off the roof and wouldn’t you know, the thing caved in and I put the sleigh down in the farmyard about the time the family came running out of the house. Everyone was OK and I gave out the presents one on one and when I turned back to get in the sleigh, well, you know how the Santa’s breed of reindeer makes AGH?”

He furrowed his forehead at me. 

“Anti-Gravity Hormone,” I said.  “Well, those animals got awful hungry with the cold and the snow and all and they smelled some of those apples still at the top of the apple trees there around the farmyard and, well, you just can’t trust those reindeer with your back turned.  Except maybe Prancer, and even him…

“So I turned around and those reindeer were browsing on the twigs at the top of the tree, getting the mummy apples, they were going at it pretty good and wouldn’t you know I had to borrow a ladder to get back in the sleigh, and climbing that thing isn’t easy when you’re as short and fat as I am, it’s not like you can just put your finger on one side of your nose and whoosh you’re up like you can in a chimney. 

“That was the year I got a letter from a fellow in the jail in Lame Deer, Montana, on the Northern Cheyenne reservation.  What he wanted, see, what he wanted was lithium.  I had checked my list on this guy, twice, and I can tell you he hadn’t been good.  Really, pretty naughty.  But I looked at what he wanted, and, you know, I figured, lithium.  You know, why not.  Ever since then someone asks for lithium, I don’t even check the list, I just figure I’ll make the stop.  And it’s a simple package, doesn’t weigh much, not like those cotton-pickin’ ponies.  Doesn’t take hardly any elf labor.

“Me and the reindeer we get back from a run and we’re really, really tired.  So are the elves, so is Mrs. Claus.  But we get the animals out of the harness, and even if the elves are getting sleepy I get ‘em to hang up the harness, we don’t use saddle soap anymore…”

“No?” he asked

“No, we went to all-Kevlar harness, oh, heck, it’s got to be twenty-five years ago.  Just saves one more step when I bring in the sleigh.  Takes twenty-four elves to curry-comb the reindeer and they’re getting a little edgy at that point in the season.  If they haven’t mucked out the reindeer stables, well, I got to get on ‘em about that, oh, I’d say three years out of four.  But me?  I’m the one that feeds ‘em.  You know, we got some really first class hay out of Montana last year, good clean alfalfa.  Not like that, you know, Santa shouldn’t use such language, so I’ll just say stuff with a capital SH that we were getting out of Siberia.  Tell you what, don’t sign a contract with a Chechen.  I should have known better than to deal with a company’s got everyone on the naughty list.

“By the time the reindeer are taken care of and stabled, we sit down to darned fine meal.  You know those dry does in the reindeer herd, I’ll tell you what we eat pretty darn good.  Then we go take a nap.  Now, remember it’s the Arctic night, and we just snooze for a couple of months.  When we get up Mrs. Claus keeps making breakfast, coffee, doughnuts, reindeer salami and cold storage eggs, till the sun comes up on March 23, and then we’re back at it.  Magic reindeer drop their antlers when the sun comes up like that, that’s when they stop making AGH and they don’t fly till they’ve scraped their velvet.

“Then you gotta watch out.   Rutting deer are bad enough, but when the flying reindeer go at it, it’s dangerous for the aircraft.  We took to tethering ‘em just before they take off.

“But there was one year, ’01, Vixen was still in velvet and I had a bad run of Barbies in the shop…”

He raised an eyebrow.

“Yeah, you know, the Somali elves had just come on board and they didn’t know metric from English, and if you think Barbie’s proportions were unrealistic, that run was just plain science fiction.  Anyway I just didn’t send the elves out to tether ‘em quick enough and before you knew it, Vixen was off.  You know how those polar air currents are.  Well, he went chasing the does outside of Atqisut Pass.  I had to harness up an empty sleigh to go looking for him, and he was darned hard to catch when I got there.   Good for me he was closing in on a bunch of estrus females when some Inuit opened fire and he lit out of there just as we were flying in.

“That’s the year I put GPS tracking onto their collars.”

Dear Readers:  This is my first attempt at a humorous post.  Please let me know what you think.

An imposter impersonates impersonators impersonating an impersonator

December 15, 2010

In the evening I had a short pause

Why did I do it?  Because.

     I suppose I look cute

     In the funny red suit

An imposter of old Santa Claus.

As a doctor, people frequently ask me to do things that have nothing to do with medicine.

I worked with the Canoncito Band of Navajo early in my career.  Shortly after Christmas in 1984 a patient brought in a digital watch and asked me to set it for her; the conversation took place in Navajo.  She had an exquisite silver and turquoise watch-holding bracelet she’d placed the timepiece in.  I read the instructions and set the watch as requested, struck by the contrast between the hand-crafted jewelry and the cheap, mass-produced electronics.  The patient couldn’t tell time, and if she could have, time on a watch has no meaning in the Navajo world.

Shortly after I arrived in Keosauqua, I received a call asking me if I’d play Santa Claus at the library.  I’d never done such a thing before, I said, but I’d be willing to as long as I didn’t have to provide the suit.  The outfit, she assured me, would arrive two days before the event, which would go from 4:00PM to 8:00PM, on weekend evening.

Not long after, the date changed to a Wednesday.  No problem, I said, but remember I can’t be there until after clinic, which ends at 5:00 if I’m lucky

At 4:55, the nurse poked her head in to tell me my last patient was ready.

A non-trivial injury required x-rays, which weren’t ready till 5:22.  I explained to the family the importance of the diagnosis and arranged follow-up with a specialist.  In the middle of the explanation my cell phone sounded.  Would Santa be showing up?

Yes, I answered, but I still had patients to take care of.

I didn’t get my hurry hormones going and I didn’t finish my documentation.  I got into the Santa suit as fast as possible and made the three-minute drive to the library.

Santa impersonator outside of the Keosauqua Public Library

 

I don’t celebrate the holiday that Santa represents, and the Vatican de-canonized St. Nicolas. Thus, current Santa suit wearers impersonate impersonators, making me an imposter of an impersonator impersonating an impersonator.

The kids came and sat on my knee, serious in asking for things I’ve never heard of and frequently couldn’t understand.  I looked into faces and diagnosed allergies. I listened to coughs I knew were asthmatic.  I smelled parental smoke on innocent victims.  I found the frequency of speech impediments more shocking that the young materialism.   I spotted two children as adopted. 

Waiting in line to talk to Walkaboutdoc, aka Santa Claus

One blond girl missing two front teeth asked if I were the real Santa Claus.  “What do you think?” I asked.  She couldn’t decide.  I said, “You know, under my fake beard I have a real beard,” and I lifted the false white plumage up to reveal my gray facial foliage.  Her eyes widened.  “You ARE!” she exclaimed.

Mennonites and CT scans

December 14, 2010

For the patient, here is the plan

Forget the equivocal scan

     I don’t need much urgin’

     To call up the surgeon

With the results of the tests that we ran

SYNOPSIS:  I’m a Family Physician from Sioux City, Iowa, making a career transition to avoid burnout.  While my one-year non-compete clause ticks off I’m traveling, doing locum tenens, and having adventures.  Right now I’m working at Van Buren County Hospital in southeast Iowa, where there are no stop lights or fast food.

I’m on call in Keosauqua, Iowa, where the mid-level providers (Physician’s Assistants and Nurse Practitioners) take first ER call, and the MD or DO provides back-up and more definitive care. 

The day till now has run on a low stress level.  As with any other day I care for patients, I came across a physical finding I’d never seen before, a soft lump where I should find hard bone.  The MRI machine comes in a trailer tomorrow and will give me an answer.

I hesitate more about ordering MRIs now than I did when I owned a part-share in a scanner, but I seem to order the same number.  I’m likely to fill out the paperwork and jump through the insurance company hoops when back pain goes down the leg and doesn’t get better, when mysterious physical findings can’t be denied, or when the patient worsens.  I find a lot of occult fractures, that is, broken bones that didn’t show on x-ray.

I remember patients I sent for MRI when I had profit motive to do so; scans showed problems malignant and benign, and surgeons prolonged or saved lives.

Keosauqua has growing Amish and Mennonite populations.  They call us English even if we aren’t English, we call them Pennsylvania Dutch even if they don’t live in Pennsylvania and they aren’t Dutch.  Their economic basis depends on subsistence farming; their agricultural methods qualify for the trendy buzzword sustainable.  I haven’t seen horse-drawn vehicles on the roads here but I have seen traditionally dressed people at the café and in the hospital waiting room.

A call comes from the ER for me to evaluate a Mennonite patient.  I find the family straightforward, respectful, and friendly.  I’ve seen the problem at hand hundreds of times.  The CT scan, ordered before I saw the patient, comes back equivocal, but my exam makes a firm diagnosis requiring a surgeon.

Our surgeon and I have come to similar places in our careers: we want to work but we want to slow down.  His solution to the full-time-means-eighty-hours problem led him to work two weeks out of four, while I intend to go to a forty-hour week when I get back to Sioux City. 

Thus, the patient arrives while our hospital’s surgeon is en route to Florida.

I admit my surprise when the matriarch pulls a cell phone from her skirt pocket.  You should have been there.  The family requests a surgeon across the state line in Missouri.

I make the call requesting a transfer, speaking to the surgeon herself.  My presentation of the patient comes off smooth and articulate.  

The family drives into the night, subsistence farmers with hard copies of lab results and a CD copy of the CT scan.

Contrast is the essence of meaning.