Archive for the ‘Nome’ Category

Foxes, itches, triumph, and hunter: on the cusp of leaving Nome

April 1, 2015

On the med list I’m pulling a switch
‘Cause my patient came down with an itch
Now they’re getting the sleep
That’s restful and deep
And for trazodone I found the right niche

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, travelled and worked out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) I can get along with. Right now I’m back to Nome from temporary detail to Brevig Mission.

I took care of a patient with a very bad diagnosis and a very bad itch. I will leave it up to the specialists to try to change the course of the disease, here in Nome I will try to relieve suffering. Because itch in the context of unrelenting pain constitutes torture. We looked over the med list.

Me: Aren’t you allergic to codeine?

Patient: Yes, it makes me itch, real bad. Same with the hydrocodone.

Me: Stop picking at yourself. Why do you take the oxycodone?

Patient: Beats me. Doesn’t work. That’s why I finished ’em early.

Me: If they don’t work, why do you take it?

Patient:

Me: Maybe oxycodone is making you itch. Let’s try stopping it.

Patient: But how am I going to sleep?

Me: How are you sleeping now?

Patient: I’m not. Those pills don’t work.

Me: Maybe we should stop them.

Patient:

Me: How about if I give you a sleeping pill to help you sleep and you come back next week. How about trazodone?

It took some explaining, but the patient came in, looking fresh and happy and focusing a lot better, having slept well 4 nights in a row, and now having much less pain. Because (everyone knows) that good sleep helps a person deal with pain.

And another demonstration of the principle of ABCD (Always Blame the Cottonpickin’ Drug).

***

I can post this about the young man because I got permission from him and his mother and because everything is on Facebook. Well on the way to being a hunting legend at age 14, he got his first polar bear at age 11, same year he got his first bowhead whale. He has lost track of the number of walruses he’s gotten so far this year. I still won’t publish his name or what he came in for.

***

I stepped into my cubicle about 10 in the morning and saw a red fox run past.

Foxes hunt at night, any abroad by day raises suspicions of rabies. At home, if I see raccoon, skunk, or fox outside of dusk, dawn, and night, I will seek a weapon to dispatch the animal. In Barrow, we assumed rabies in all arctic foxes.

The furry red animal ran along the north side of the building, around to the west. I said, loudly, “There goes the fox!” and strode briskly to the other end of the clinic to try to get another look; I worried it might head to town. I didn’t see it again, and decided it dens either under the hospital or in the maze of construction dross nearby.

****

The first patient of the day felt really, really good after the vitamin B12 shot yesterday. Best in years; better sober after that shot than drunk.

Which made my day.

***

I leave tomorrow after an abbreviated afternoon clinic. Staffers have come in to wish me well. I got a great going-away card, a very trendy tote bag, and a pair of hand knit socks. Along with the story of the wool (starting with the sheep) and the WWI-era sock knitting machine.

Brevig back to Nome

March 31, 2015


I flew out and back Bering Air
My clothes in layers I’d wear
I come and I go
In the ice and the snow
And a bag of dry fish I did share

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, travelled and worked out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) I can get along with. Right now I’m on temporary detail to Brevig Mission from the hospital in Nome, Alaska.

I don’t sleep well the day before I travel, without regard to mode of transport. I rose early and showered and packed and ate.

Then I napped, for the best sleep I got all night. By 8:00AM I logged on to the computer.

I worked a steady pace through the morning. At noon the staff left for lunch. I stayed by myself and ate trek mix while I read a Jonathan Kellerman novel (I write better than he does, but he has the genre formula nailed down).

With but one afternoon patient scheduled, I had time to finish documentation. The Bering Air agent, who had showed up during a house call to check me yesterday, came in. The plane would be a little late, he said, flying from Nome to Wales first. He needed my weight. I offered to get on the scale (declined), and gave my best honest estimate. But he also needed weights on pharmacy and lab air freight.

Things had finished when the staff asked me to add in another patient. I looked at the clock. Plenty of time before the 4:00 departure. Sure, I said.

And I said that for the next three patients as well. I luxuriated in unhurried patient care. And each time I entered the data into the computer in a timely fashion.

I told the staff what a great time I’d had. They told me to come back in summer for prettier scenery. I looked out at the snow-covered hills and the frozen Bering Sea, and wondered how things could ever get prettier. They assured me they would. And they talked about how Brevig never sleeps in the summer, how the place bustles with activity. And about the fishing.

I said that I would have like to have tried dry fish.

The staffers looked at me in dismay. I should have spoken before, they said. And I saw how my shyness, from not wanting to impose on my hosts, appeared as standoffish. And all that announced at 3:50PM.

A Community Health Aid (CHA) bundled up faster than I could imagine, and jumped on her ATV.

It takes me a good deal longer to get on my arctic-grade bib overalls than the CHA’s near instantaneous preparation. As I mounted the ATV behind a diminutive staffer, we saw the plane coming in from the northwest.

The CHA on the ATV passed us on the hard-pack snow of the village street, and the staffer in front of me took the bag of dry fish from her without slowing, as casually as if it happened every day and as smooth as the railroad used to pick up sacks of mail. Approaching the airport, we saw the only truck in town, a 4WD club cab pickup.

I needn’t have worried about keeping the plane waiting. We pulled up before the pilot, working on his documentation, killed the engines.

Wearing my arctic layers let me confine my baggage to 1 day pack. I sat as instructed just behind the passenger in the co-pilot’s seat.

After a 5-minute flight to Teller we deplaned one passenger who had flown from Nome through Wales and Brevig to get home.

Ice melting into puddles astounded me when we arrived in Nome with a temp 20 degrees higher than Brevig when we left.

Contrast remains the essence of meaning, even when just barely above the melting point.

Still making housecalls

March 26, 2015


The sun on the snow gets so bright
Reflecting the light off the white
The stuff new to me
Is wonderful, see,
And Aurora brightens the night.

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, travelled and worked out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) I can get along with. Right now I’m on temporary detail to Brevig Mission from the hospital in Nome, Alaska.

I make house calls. I enjoy them. I don’t do them very often.

When I worked in Navajoland, the war between the bureaucracies resulted in the demolition of a perfectly good clinic with the empty promise of a quick replacement; I got mean after two weeks of pay with no work and talked the Public Health Nurse into driving to hogans. I treasure those memories of the community I got that way.

Sometimes at home “housecall” means the patient comes to my house.

Here in Brevig I made three house calls on foot today. The Community Health Aide (CHA) and I walked together, through the blinding bright sun-on-snow, in bitter cold and wind.

Confidentiality precludes discussion of patients and problems in any but the most general terms. All three patients would have had difficulty getting to the clinic.

But I can talk about the context.

All the houses had portico closed on three sides, protecting the outside door and a space between the inner and outer doors. Two had firearms casually stacked in that space; I noted .22s, .223s, 12 gauges shotguns, all with outer finishes roughened by prolonged use in hard conditions. Each home had a first-class wood stove in the living area; no trees grow here but lots of wood drifts on the beach.

I saw frozen pizza boxes and traditionally dried salmon. Tabasco sauce bottles sat next to peanut butter jars. A single gleaming spark plug sat on a washing machine next to a rusty box/open end wrench. People sewed furs from sheep, beaver, seal, and wolf with waxed dental floss.

I commented to the CHA how the smallest, most mundane details of someone’s daily life fascinate people from other places; for me a flock of wild turkeys or a doe and her fawns in my backyard rate a yawn but would bring her wonder, while Northern Lights every night and a nearby island good for hunting seal knock my sox off.

During the visits people talked about bingo. I don’t gamble, but bingo on the Bering shore promised a unique experience, and at 7:00PM, my clinic documentation done, I suited up and walked out into the brightness.

I did not find the bingo game.

In a village this small and this isolated, the children play as freely as I played in the 50’s. Two, who recognized me from clinic, came up to show me their puppy while I wandered.

Back inside, my glasses frosted over, rendering me sightless till the ice sublimated and the temporary darkening relaxed.

I napped and read until a patient came in with a CHA at 9:00PM.

Not sick enough to warrant a Medevac, but definitely in need of an IV and a few 21st century pills, they left in the dark an hour and half later.

Duff, dog sled, and death

March 9, 2015

I wouldn’t mind being the Duff
Had my leader charisma enough
Mine did, for sure,
Though there was no cure,
He was courageous, kind, brilliant and tough.

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

I find the Gold Coast Cinema here in Nome so unique that I saw The Duff, a teen angst genre film.  The title refers to the Designated Ugly Fat Friend; while not necessarily fat or ugly, to qualify as a Duff one can’t be as attractive as one’s friends.  Find a clique, you will find a Duff. Not a surprise  though  we don’t like to think that human groups have pecking orders.  If you have an alpha, you must have someone lower on the hierarchy, and the one at the bottom, the omega, becomes the Duff.  In my experience, and in the movie, the Duff has more IQ points than the hot friends. 
The script pointed out that for every measure of social desirability (looks, strength, money, power), someone always occupies a higher position.  Thus the omega depends on the alpha as much as the alpha depends on the omega.
Taking the sled dog ride I bought at the Nome Preschool annual fundraising auction, today I learned more about sled dogs than just their hierarchies..
Tom, the musher who donated the item, picked me up on a very clear, very cold day, and brought me to his home 15 miles north of town.  Of course I quizzed him on the sport.
Working dogs are happy dogs.  Most come from the Alaska Husky breed, which lacks AKC credentials.  A team usually starts with 12.  As the years have gone on, the race has ended more quickly and the dogs do better physically.  While mushing, these animal ultra-athletes will eat the equivalent of 22 Big Macs a day.  Deciding to run the Iditarod requires a 3 month commitment and a huge monetary investment.  A good long-distance dog trots rather than gallops, in a smooth, level-back gait.
The lead dogs, furthest from the musher, have standing in the hierarchy, but must make a lot of decisions.  The next pair back, in the swing position, have the responsibility for making sure the turns aren’t made too sharply.  The pair closest to the sled, the wheel dogs, take a lot of jarring from pulling, and females have more resilience than males.  Most dogs prefer the other, team positions between the front and the back.
Tom kindly surveyed my gear, gave me toe warmers for my socks, and lent me a seal skin hat and a balaclava.  He let me mush on the return trip.
The immense work in dog sledding comes from maintenance of the team; just yelling HIKE was pretty easy compared to harnessing the canines.  Learning to keep the tug line (that nylon rope that connects to the sled) came easily.  I found my short ride in a dog sled exhilarating, in a primal way difficult to describe, and very cold.  At the end, despite my arctic grade layers, the cold had sapped most of my energy.
When I returned I learned a friend had died.  An excellent physician, a good husband, and a devoted father, he taught me a great deal about leaving judgment out of my day, and, in the process, having more energy and getting better clinical results.  My tears lasted a short time, we had watched this event approaching for years.
He led the team by example, he kept us focused on the clinic’s mission, and, in the process, kept us believing in it.  His charisma bound the group together and prevented us from breaking under terrible strain.  HIs guidance, hard work, and good, sound personal advice brought light to my three years at the Community Health Center. I admired his intense personal courage, maintaining a strong work ethic and a sunny countenance in the face of terrible disease.
With a leader like that, I never objected to not having the lead dog or alpha position.  I wouldn’t have minded being his Duff.
 

March 6, 2015

One winter Sunday I strolled
Towards the Bering Sea in the cold
For a G-rated flick
Not my first pick
But at the theater they call Coast of Gold

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

The first time I went to college, I went as a music major. Even though I understood it, I intensely disliked opera; I found the score weak musically and the libretto (the story) frivolous at best, and always poorly written. The comic opera lacked funniness.

My dislike of such a genre extends to musical comedy. It doesn’t make me laugh, the music doesn’t make me want to dance, and the lyrics don’t inspire me to memorize them and sing them in the shower.

I make it a point to avoid G-rated movies; I find scripts aimed at children, well, juvenile.

Nonetheless I walked over to Nome’s Gold Coast Cinema and Subway Shop to see Annie.

I went for the experience and to have an excuse to walk in 5 degree weather to the edge of the Bering Sea.

I found modern, stadium seating and a ticket priced at $9. The Subway sandwich shop in the lobby added previously unknown variety to the concession menu. And probably few Subways offer popcorn and movie candy.

Perhaps because the weather just turned cold, or perhaps because school goes back into session tomorrow, the crowd numbered under 50. Children in heavy show boots clomped up and down the stairs most of the performance, going to and from the bathroom and the concession stand.

At the end of the show I leaned my back against the wall of the outsized foyer (in Alaska architecture called the Artic Entry, in Inupiaq the cunichuq, which allows for donning and removing layers) and slipped on my Yak Trax, a device of coiled steel spring and rubber, which, applied to the soles of one’s boots, gives traction on ice.

Outside, though 5 degrees colder than yesterday, I found I adapted quickly to the winter and I stood on the seawall overlooking the Bering Sea. I gazed off to the west, towards Russia, a country I have no urge to visit.

I looked over Norton Sound, and thought of the 1950’s John Horton song, “North to Alaska” and the classic line, Just a little southeast of Nome.

Southeast of Nome will put you into some very frigid water; this town is located on the southern shore of the Seward Peninsula.

Alas, popular music failed in historical accuracy. Sort of like comic opera failing at comedy.

February 24th, 2015, a day that will live in infamy

March 3, 2015

When it comes to the drug they call pot
What is it good for? It’s not.
But they were quick on the draw
To pass a new law
And speed up the memory’s rot.

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Marijuana use runs rampant across the US.

In the early part of the year I asked a patient, a single parent of five and a major pothead, if they would hire a babysitter who got stoned every day, and we agreed that any intoxicant impaired ability to care for children.

My first Monday back brought me to contact with patients running into problems as a direct result of their marijuana abuse.

Mostly hemp excess happens in the context of abuse of other drugs, usually tobacco and alcohol. All three contribute to poor memory, seizures, depression, loss of restful sleep, low testosterone levels (both sexes), low sex drive (both sexes), lowered resistance to infection, poor pain tolerance, social isolation, and irresponsible parenting.

Recently I had a heart-to-heart talk with couples in the maelstrom of dysfunction; the medical problem that brought them in stemmed directly from marijuana abuse. I correctly guessed that both had cold, controlling, distant mothers, and exciting, generous-to-a-fault fathers who failed to follow through on promises and brought repeated disappointments. They readily admitted that each could tell me everything wrong with the other and neither had much of a handle on their own failings. I pointed out that drug abusers can’t exist without enablers, and the cycle can be hard to break because it has roots more than a generation old.

I took a step back and talked about myself. The vast majority of med students, 70%, come from chemically dependent households and most of the rest had other sources of dysfunction in their nurturing families. I skipped the details of my upbringing, but I told them about Alanon and the Adult Children of Alcoholic Parents movement, which use the same 12 steps as Alcoholics Anonymous, and how I went to meetings for 7 years. Every strength is a weakness, every weakness is a strength; it all depends on what you do with them. We agreed that their current approach didn’t work. I replaced a benzodiazapine tranqulizer with Dilantin (most common use=seizure or migraine, but a good second or third choice for almost everything), recommended 12 step meetings for both, and called in Behavioral Health Services.

I learned more about human behavior in dysfunctional families from Alanon than I had from med school.

My last patient requested a back-to-work slip, which I cheerfully supplied. But in the process I uncovered alcohol and marijuana excesses; I accepted at face value the patient’s assertions, and said, “Let me be the first to tell you that nicotine, alcohol, and marijuana will make any medical problem worse and none of them better.”

I could more easily believe that the weed wiped out memory than that all previous docs had missed the chance to educate the patient.

During my two weeks off, the state of Alaska legalized marijuana on February 24th, a date that will live in infamy for those with intact memories, but the pot heads will promptly forget.

I suspect that those in power prefer an apathetic electorate with a poor memory.

A fund raising auction at the Convention Center

February 18, 2015

The city of Nome has a flag

They imprinted it all over some swag

Just for the kiddos

I made the right bid-do

On a bucket, a bottle, and bag

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

When one says Convention Center in a town the size of Nome, one means a building with less floor space but better acoustics than the high school gym.  Adequate for the Nome Preschool annual fund-raiser, it seats about 200.

I bought tickets for the evening’s raffle last week, and, in the spirit of supporting community institutions, walked over to check out the auctions.

I bypass the home-baked desserts and chili, browsing items on the silent auction table.  With no interest in cosmetics, fragrances, and home-made garments, I note winter clothing bearing logos for telephone, construction, and fuel companies.  I discard the idea of a wrench set, or anything else difficult to transport.  I consider the knife and flashlight sets.

I find an item entitled City of Nome Swag: a plastic bucket holds a Frisbee, T-shirt, fabric shopping bag, water bottle, and ball cap.

I like to bring back small stuff from my travels, an ivory polar bear from Barrow, a ball cap from Waikiri.  And this batch would suit my purposes.  Especially the water bottle.

I sit with a PA and a CMA from work.  We swap stories about Alaska.  I learn about an island where statute prohibits locking the car or the outer door of one’s arctic entry, because bears regularly harass the population and people need to have shelter in a hurry.  We talked about Adak Island, I hear about being stuck for two weeks because of winds.

The live auction list reveals a lot about the location and the town’s values.  The Natives invented the ulu, a kind of knife very useful for dressing hides, and the program sports three of them, one for sewing.  I find a half-dozen kuspuks, an ornate, hand tailored upper garment with a hood and an elaborate kangaroo pocket.

The auctioneer pitches tryouts for the Community Theater, and emphasizes that we have gathered to raise funds.  He chants through pieces of local art, a home dog grooming kit, and a toddler’s Ski-Doo jacket.  The first item that holds an interest for me, dinner at every restaurant in town and movie tickets for two, also catches the crowd’s fancy; the bidding passes the triple digit mark and keeps going.  In the course of the evening, the other items that fetch the highest prices include 100 pounds of air freight (three different airlines), 10 pounds of crab (three lots each), a one night fishing getaway to Niukluk river, a helicopter sightseeing tour for 3, an hour of bluegrass music from Landbridge Tollbooth (a local group), Nome Discovery Tour for 4, 100 gallons of fuel, and 40000 frequent flyer miles with Alaska Air.

Every 15 items, the action stops.  A child picks a door prize ticket (cash), and the MC reads the names of successful silent auction bidders from two or three tables.

I outbid everyone for the Bucket of Nome Swag.

In the third round I buy a dog sled ride. My bid goes over the triple digit mark.  Later I find out the musher, the District Attorney, qualified for next year’s Iditarod.

I look forward to the conversation as much as the ride.

Aching and waiting for the CT scan

February 17, 2015

It starts with a drip from the nose

And progresses with an ache to your toes

What should you do

When contracting the flu

While waiting for the clinic to close?

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

My nose starts dripping at 4:00PM, while finishing a visit with a patient with a knee problem. I blow my nose, wash my hands, and apologize. A vague sensation of not feeling quite right accompanies an explanation of how to apply a cold, not frozen, can, not bottle, of regular, not diet soda to an area of overuse.

I exit the room, have my nurse print the patient’s depart papers, and ask about the afternoon’s first patient.

I started with that patient on time at 1:00PM. While I washed my hands, I noticed shortness of breath. I listened to the account of all the things that had happened since a recent surgery. After examination, I told that person my concern for a possible blood clot in the lungs, then started in the process of ordering a CT of the chest (and, because of other problems, other places).

The welcome assignment to Same Day duty brought my most intense day since arriving in Nome. Starting with an empty schedule, the morning filled with people who had sickened or worsened in the last 72 hours. I moved efficiently, discharging the last morning patient promptly at noon. I bolted up the stairs to the cafeteria, inhaled lunch, and descended to finish the morning’s documentation. With satisfaction every time I hit the SIGN box, I started the afternoon with no morning leftovers.

Nothing happened quickly for that first afternoon patient. While I cared for others with respiratory infections, orthopedic problems, rashes, and psychiatric conditions, complicated by betrayal, bitterness, and overwhelmed emotional resilience, we had delays getting the lab to draw the blood, and delays getting the results.

The nurse tells me that the patient hasn’t yet gotten the IV for the contrast.

However late, we need the result before the patient can leave.

I start with my 4:00 PM patient at 4:05. At the end I discuss the difference between sinusitis and the common cold. I describe the relationships between stress, alcohol, marijuana, tobacco, and the immune system, and make recommendations.

I sit down at the computer and I start the depart orders for that patient: diagnoses, medication reconciliation, follow-up, and patient education.

I wait for the CT scan to start while I start the afternoon’s documentation. At 5:00 my nose has gone from dripping to running and I worsen. My forehead warms my palm, but I keep keyboarding.

At 5:15 I ask the nurse for a portable thermometer and receive, to my surprise, real mercury in real glass.

The patient enters the CT scan while I mutter that I don’t feel good; at three minutes the thermometer reads 99.0. The glass bulb stays under my tongue.

Long ago I learned to keep the thermometer in till it quit going up. I keep computing, checking the silver line every three minutes, till 5:45. The worst of the documentation ended, I await the viral onslaught with a near fever, 99.5.

At 6:10 I can tell the patient, “You have no blood clot in your lungs, and the rest of the studies showed no surprises.”

At 6:15 I walk out, feeling even worse. The dry, hacky cough (confirming my diagnosis of influenza) starts while I crunch across crusted, packed snow in the gathering subarctic, subzero gloom. The half-mile back to my lodging takes me 15 minutes. After 2 acetaminophen, a Tamiflu and a liter of fluids, I crawl into bed and don’t crawl out till morning.

Feeling much better, I walk back to hospital in 10 minutes, arriving before business hours. Funny lab results bring me to research multiple myeloma until 8:30 when I call the infection control nurse. She comes to my cubical.

My story recounted, I ask, “Do you or don’t you want me seeing patients today?”

“What would you tell a colleague?” she counters.

To answer a question with a question constitutes a dodge, but, in this case, a legitimate one.

I said, “Generally I send folks back to work when fever free for 24 hours, and I never actually ran a fever.”

And in fact the worst part of my contagiousness happened in the 24 hours before my nose started to drip.

Old patients with old ATV, delusions of a hypothyroid, improving patient flow, what people here want to win, and Eskimo salad

February 8, 2015

Here is a word to the wise,

The thing for which everyone tries

When it comes to the raffle

The stuff shouldn’t baffle

When it appears as a winnable prize

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

The closer I get to Medicare age, the nicer I treat those over 70. I quit trying to push them around years ago; it doesn’t do any good. So I don’t tell them when to come back, I ask them when they want their next appointment. A 76 year old patient today considered the question. “My ATV’s old and hard to start,” he said, “I had to use a hot water bottle to get it started today.” Which I took for a polite way of saying he didn’t want to come back till spring.

***

During residency one of the recently minted Family Pratitioners told us 14 patients a day covered his overhead. During my quarter century of private practice, 32 a day was light, 36 just right and 40 left me frustrated and rushed. I spent many years trying to squeeze too many patients into too little time. After the installation of this electronic medical record (EMR) system, the administration here in Nome recognized inherent slowness and lowered the expectations to 12 patients a day for the experienced docs and 8 for those just learning the system. One month into my time in Nome has left me begging for more patient flow. And yesterday I had the great good fortune to be placed on the Same Day duty: I would start with no appointments and see those people who needed care that day. Dermatology occupied half my case load, I saw 11 patients and got through with documentation at 5 sharp. I had a psychiatric patient whom I could rate as either difficult or impossible due to delusions but really had a great time treating their dramatically dysfunctional thyroid. I know the patient’s contact with reality will improve when those medical problems get handled, but I don’t know how much.

***
People don’t buy raffle tickets unless they want to win something on the list of prizes, thus such lists speaks volumes about what people want. Nome’s preschool will have their annual fund raiser this Saturday and I’ll attend the silent and regular auction.
Prizes Include:
1. Weekend Getaway – 2RT tickets, OME-ANC w/3 nights @ Captain Cook + $1,000 spending cash (Q-Trucking)
2. Two Round Trip Tickets, system-wide (Alaska Airlines)
3. Two Round Trip Tickets (Bering Air)
4. One Round Trip Ticket (Rav’n Alaska)
5. One Hundred Gallons of Fuel (Bonanza Fuel)
6. Ruger 10/22 and Smith & Wesson 22A (Charley & Jennifer Reader)

***

Highlight of the intranet email today:

Eskimo salad for sale: includes Reindeer meat, walrus meat, smoked fish, imitation crab, green and red peppers, onion, carrots, seaweed and greens mixed in seal oil. $20.00

Due to the fog today, flights are being canceled. If you had hotel reservations, please call the hotel you were booked at and reschedule your stay or NSHC will be charged for a no-show. Thanks

Doing the best for a difficult patient

February 2, 2015

Sometimes it’s almost a test
The inappropriate narcotic request
If it’s bad that I judge
I just will not budge
For the patient I’ll do what is best

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Confidentiality limits what I can say about my patients, and what I write here may or may not relate to a particular patient or a composite of patients.
Our country has a major problem with prescription narcotics or opiates, painkillers with significant feel-good potential. I find them useful in terminal conditions with long term pain, like cancer, and in short term conditions like kidney stones, fractures, and burns. When I get to a new location, patients frequently flock to me to see if I’ll generously dole out the prescriptions. The word leaks into the drug-abusing community very early that those who seek from me come away disappointed.
I worked the patient in on request from an ancillary service, on short notice so as get the patient to the scheduled commercial flight in time.
Most of what a doctor knows comes from what the patient says, physical exam, lab, and x-ray account for less than 10% of medical decision making. This particular patient couldn’t come up with a straight story.
After twenty minutes of rambling, I made the Time Out signal and said, “Do you know that you interrupted me every time I tried to ask a question?”
No, the patient hadn’t realized it. And I had made clear that I would not prescribe the narcotics so stridently demanded.
After all, if the patient had asked for anything else inappropriate and dangerous, say, plutonium or a whole vial of Botox, I wouldn’t prescribe it, either.
The doctor always wants to know these things about the pain: context, quality, intensity, location, duration, modifying factors, and timing pattern. In short order, I figured out the patient really couldn’t answer the questions. So I would have to guess, and my best efforts would have to be at the veterinary level. I proposed an x-ray.
The patient emphasized the request for pain pills and needed to get to the airport. And wouldn’t I please call the airline and have them hold the plane?
I could have someone do that, I said, and I can do a lot of things for chronic pain, and I really like normalizing a restorative sleep pattern.
The patient didn’t want the sleeping pills but the pain pills, but then let slip the 23 pound weight loss, that had occurred but she couldn’t recall the time interval.
I knew right then the patient couldn’t make the plane. And I said so, noting the slack flesh and wrinkled facial skin.
I have to work harder for some patients than for others; I find those who require more intelligence or persistence. My job is always to do the best thing for the patient, no matter how difficult, demanding, or inappropriate.
I ordered the x-ray, blood count, chemistry panel, sedimentation rate, and thyroid/diabetes/B12 and folate tests. Then I started slogging through old records.