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Bringing Alaska fish to the 500-year flood

June 17, 2019

We flew back to the corn belt

All the way the worry I felt

I’d hoped, I had chosen

To keep the fish frozen

But feared the hundred-pound melt. 

 

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 Arctic Alaska, rural Iowa, suburban Pennsylvania, western Nebraska, Canada, and, most recently, south central Alaska.  I plan to take a few weeks vacation

At this time of year, close to the summer solstice, Alaska nights never get really dark.  We left Friday morning in the semi-darkness, and drove to the Kenai airport.  We saw one caribou and no moose on the way.

The day before we’d brought frozen halibut and salmon to one of the many fish processors for packaging with dry ice.  We put most of the fish into 50-pound boxes, and arranged to ship the remainder, about 36 pounds, to our friend Les, in Anchorage, who took us out halibut fishing: https://walkaboutdoc.wordpress.com/2019/06/08/the-biggest-fish-i-caught/

I worried about the fish.  I have had enough summer travel plans drowned by thunderstorms and delayed flights, occasionally arriving 2 or 3 days late.

When we finished having our bags weighed, I identified myself as a physician to one of the ticket counter staff and advised her to get her thyroid checked.  She replied she already knew she had a problem and she intended to restart her medication.

By the time we walked out onto the tarmac the light had brightened enough to show colors.

We go out of our way to sleep poorly the night before a long plane trip so that we sleep on the plane.

The frozen fish stayed at the back of my mind, through Kenai, Anchorage, Seattle, Portland, Omaha, and into Sioux City.

But the worry didn’t keep me from sleeping, as per plan, on the plane.  Somewhere over the Rockies, flying into the night, the sun went down.

Our friend, John, picked us up.  We loaded the luggage and the two pieces with fish into the trunk.

The darkness of the Nebraska night, something we haven’t seen in months, came as a relief to our eyes.

Much of the Midwest has seen record flooding.  When I came back from my first locum tenens trip, in 2010, I found the Interstate closed in Omaha, with Sioux City onramps repurposed as boat ramps.  They called it the 500-year flood.

Now, less than a decade later, we have another 500-year flood. John navigated through the blessed darkness, detouring around closed Interstate highway.  We chatted about our mutual adventures while Bethany sleeps in the back seat.

Finally at home, with the coolers in the basement, I cut through the tape to find the fish still solid frozen.  We dumped it into the freezer, filling it to the gunwales.

We would not have had room for the 36 pounds of fish we sent to Les.

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Unsustainability ends in warm poignance.

June 9, 2019

 

In 12 weeks, I saw 53.

I thought, what a great place to be

But who’s keeping score

When you establish rapport

And on weekends, head out to sea

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, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

Thursday dawned with one patient on the schedule.

In the last 12 weeks I performed a total of 53 outpatient visits.  My busiest day had 6 patients; I had 6 days with no patients at all.

In contrast, while in private practice, the day after Thanksgiving 1994 I saw 63 patients.  (If you must know, strep throat and flu, with one patient having an active heart attack.)

I never spent less than 30 minutes per patient, a few went close to 2 hours.  Ages ranged from 54 to 90.

Few doctors in Alaska’s population centers accept Medicare because the payment schedule doesn’t cover the added expense of dealing with a truculent bureaucracy.  Thus, aside from veterans, the aged have difficulty accessing medical care.  This, the final visit of my assignment, means that the problem has worsened.

Today’s patient came in at 10:00 AM.  Mostly we talked about his medical problems.  Thus I had to ask his agenda.  What do you want to be doing in 5 years?

The patient’s agenda always trumps the doctor’s agenda.   For example, the exercise program won’t work if the patient hates it, and those who love smoking won’t quit.

My patient and I come from the same generation.  We both love fishing and know exercise’s value..  Both love our chosen professions. We both face the inevitable physical need to slow down, and we both wonder what we’ll do with our time without a schedule.

While I want to keep going at least another 16 years, he wants to be done in 5.  He’s already starting to dismantle his infrastructure.

In the end, the 90 minutes I spent with him revealed things needing investigation.  I put orders into the computer, and refilled prescriptions.

But it also gave me time to establish rapport.  By visit wrap up, we found our agendas closer than we’d realized.

I recommended a doc in a close (by Alaska standards) town with whom I worked at one time.

At the end, our handshake held warmth; under other circumstances our friendship would have grown.  It also had the same poignance of finality that has permeated this assignment.

+-+-+-

Low patient flow lacks sustainability.  It doesn’t generate enough income, and inevitably popularity will grow or wane.

But at least 4 alcoholics decided to change, including one past the age of 70, which I’d previously regarded as sobriety’s event horizon.

If I hadn’t had so much face time, I would have missed the basic problem for at least 12 patients.

Five people needed their thyroid doses changed.  I ran a lot of tests that brought reassurance but did not change management. I made one great diagnostic coup.

At least half my patients work or have worked in fishing.  Showing fishing photos on my phone strengthened rapport.

I used my Spanish 4 times.  I exhausted my Japanese, Korean, and Tagalog vocabularies.

Bethany and I had a wonderful time fishing on the weekends.

I walked out the door at 4:00 PM to clear, blue sky, bright sunshine, billowing white clouds and a perfect temp of 18 C (63 F).

I had no celebratory good-bye lunch; no thank-you cards circulated.

But I hadn’t expected any.  I did my job well: I closed down the practice.

 

 

The biggest fish I caught

June 8, 2019

For halibut you use a large bait,

The reward? A fish of large weight

At the end of the line,

The object’s to dine

But you might need a very large plate.

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, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

We met Les in residency in Wyoming in 1981.  We have been friends since.  After training, he moved to Anchorage.  We reconnected in 2010 when I worked in Barrow.

He arranged for us to fall into the dream Alaska fishing trip of a lifetime.  For a week, we’d wake up, catch our limit of silver salmon, then halibut, followed by lunch.  We found out we love fishing.

Last weekend Bethany and I went fishing again with Les, who towed his boat to Seward.

We arrived when the tourist season that sustains Seward started to blossom.  Tents and RVs of every size filled a dozen campgrounds.  Visitors to the Sea Life Center packed the parking lots.  Traffic along the waterfront crawled.

We visited Seward back in 2010, taking the train from Anchorage with no other thought than tourism.  We saw glaciers, visited the Sea Life Center, and laughed when a sea otter scrambled across the parking lot.

This time, though, we booked a bed and breakfast and we had fishing on the agenda.

A brooding beauty started the day, low dark clouds brushing up against snow-covered peaks.  We crept out of the harbor to speed into Resurrection Bay.

The morning passed futilely trolling for salmon.  In the late morning we shifted locations.

One of Les’s patients, a fishing charter captain, had clued Les to a halibut spot.  (No, I’m not going to divulge the location of this honey hole. Are you kidding?)

We dropped our lines into 200 feet of water, about an hour before the slack at high tide, when the water stops moving and the halibut like to feed.  Les rigged t-shaped leaders with two circular halibut hooks, and a 4-pound weight (unaffectionately called a cannon ball) and baits of herring and squid.

I felt my weight hit bottom, then cranked my reel a dozen times to cut down on by-catch of rock fish.

From the beginning I got a lot of activity, the end of my rod jiggling at intervals, over the course of 15 minutes.  Then nothing.

I cranked my rig up and found the bait gone.  With fresh bait I dropped the ball to the bottom again.

Less activity this time, fewer nibbles for all.  Les slipped his rod into a socket in the gunwale and went for a nap.  My rod went into a socket, too, and I found a way to sit down and face Bethany on the starboard side of the fishing deck, while keeping my hand on the rod, vigilant for thumps.

After about 20 minutes of mild action followed by 10 minutes of none, I cranked the hooks up again to find the bait gone.  I slipped chunks of herring and squid onto the hooks, took the drag off, and let the cannon ball hit bottom  This time, out of sheer perversity, I cranked the reel 13 times and sat down.

The rod tip moved, I let out a bit of line.  More jiggling, more line out.  Then the pole moved violently and consistently, and I started working the reel, telling Bethany, “He’s committed.”

A 4-pound cannon ball comes to the surface reluctantly enough, but a fish who wants to live actively fights.  When cranking didn’t do any good, I stopped till the fish let up fighting, then cranked some more.  Bit by bit, the fish arose from the deep.

My left hand fatigued, and I slipped the rod butt back into the socket.  After a while I had Bethany hold the rod while I reeled with my right hand.  Then I had her reel for a while.

When she fatigued I took the pole back.  For quite a while I cranked, and watched a bit of seaweed crawl up the line to the tip, and slide back down.  I remarked I didn’t think I was making progress.  Bethany looked at the reel and verified slow advancement.

We woke Les, and we all took turns cranking.

Finally a very large shadow showed 10 feet down, and Les went for the shotgun.

If you go after halibut you should go armed.  Les loaded his a single-shot, break-action, short-barreled .410 with 7 ½ bird shot.  I brought the fish alongside, placed my noise-cancelling muffs and stood back, clinging to the pole as the fish struggled.

A splash of water and a loud bang signaled the end of the fish’s life.  Les gaffed him and hauled him out of the water.

I have never caught a fish even close to 62 inches long and 92 pounds, and Les declared no larger fish has every been hauled onto his boat.

The halibut exceeded the length of the well by two feet; Les suspended him from an eyebolt, and constructed a block and tackle from cordage.  To keep the swinging fish from hurting us, he made the tail fast to the deck.

halibut 2019 Seward

Then we went back to fishing.

Bethany brought in a 45 lb halibut that would barely fit in the well, Les brought in a 50-pounder that would fit only with folding.  Bethany caught a benthic rock fish of good size.  When I brought in another, we decided we had enough fish for not one but two days.  Les brought us back to Seward.

Mostly we like to process fish on our own as much for a bonding experience and a time to relive the trip as to save money.  But with close to 150 pounds of fish, Bethany and I decided to pay to have our two fish filleted, vacuum packed, frozen, boxed and shipped.  We gave our rock fish to Les.

With the boat hauled out, we turned our exhausted attention to dinner.  We in fact found a place that avoids the tourist hordes by falsely advertising “Cheap Beer & Lousy Food.”

2019 June cheap beer & lousy food

Another assignment draws to a close

June 5, 2019

There are beginners, and then there are purists

There are locals, and then there are tourists

The notes that I penned

As this job comes to an end

For a doctor, a healer, a curist.

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, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

When I walked in Monday morning, I had one patient on my schedule for this, the final week of the assignment.

I knew when I said ‘yes’ to the gig that I’d start with slow patient flow that would diminish towards the end.  On the basis of anticipated small demand, I could negotiate a 4-day work week.

On my busiest day I took care of 6 people.  Altogether since March 17 I’ve taken care of 50 patients.  I have had exactly one busy afternoon, and 6 days that finished with no direct patient contact.

My schedule stands empty for the rest of the week, a sign that I have done my job to help this practice make a transition.

During the day I do a lot of medical reading, checking my IN box every 20 minutes.  I with a dozen or so prescription requests, lab results, and phone calls a day.

But the Kenai peninsula has awakened from the winter hibernation.  Outside the sun shines clear.  Looking south in the distance you can see the billowing white clouds over the sea around Homer.

At the clinic we share videos of mother moose with twin calves wading in the shallows; when we see moose in town we make sure to give them a wide berth.

The salmon have started to run up the rivers, and with the salmon come the fisherpeople, with RVs and boats and camper shells and tents.  They come with light fly rods and dip nets.  Soon the shallows of the Kenai, Kasilof, Russian, and Anchor rivers will be lined with anglers shoulder-to-shoulder in the annual spectacle referred to by locals and tourists alike as “combat fishing.”

Traffic has snarled.  Bethany went to a bakery and found a line snaking out the door.  We went to a large grocery with a wonderful selection and found crowded aisles and long check-out lines staffed with seasonal help.

For the first time since we arrived in March, this week I don’t need a jacket on my way to work.  The mosquitoes, suddenly hatched and warmed from their cold weather torpor, enjoy my exposed skin.

Bethany and I talk garden plans, and the friends we miss.  We wonder aloud about the stacks of mail, and we look forward to sleeping in our own bed.

This part of the adventure will have lasted 12 weeks, which we’ve found is the longest we want to be gone.

We’ve started to pack, we’re making arrangements to bring the fish back on the plane.

It’s time to go home.

 

More fishing

May 31, 2019

The strength and the time that it took,

With a denizen firm on the hook,

Adventure was fetching

The fish we were catching,

Were halibut, we’re planning to cook.

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, western Nebraska and Canada. I have now returned to southern Alaska. Any identifiable patient information has been used with permission.

When I took this assignment I specified Fridays off, mostly for fishing.  We found a fishing charter captain, Keith Kalke of the Ocean Hunter,  whom we get along with well, and this Friday we got up at 430 for the drive down to Homer.

We arrived at the same time as Larry and Judy (who gave permission to write about our adventure). We come from the same generation.

The morning gave us winds and waves worse than NOAA predicted, at the fine far edge of comfort.  Bethany’s scopolamine patch (TransDerm Scop) prevented sea sickness, and I watched the far horizon as much as I could.

After a no-catch morning we moved, the wind abated and waves weakened.  Keith set us up with circular halibut hooks, 2 and 3 pound sinkers, and bait fish big enough to be considered dinner in Iowa. We dropped our lines into 190 feet of water.

Judy brought up a respectable 30-inch halibut.  After Larry’s rod tip shook a few times, Keith instructed him to lift his fishpole and start reeling.

From the beginning he knew he had a big one.  Larry used good technique, lifting the rod tip to the vertical and then winding while lowering it.

Three of us kept hold of poles while the drama of a fish’s struggle for life played out at the end of 190 feet of fishing line.

We didn’t realize the size of the fish until we saw it, about 15 feet down.  Keith, who has experience with very large halibut, went forward and returned with a shotgun, taking a cartridge out of a small blue box..

Salmon, rock fish, greenling, and smaller halibut can be dispatched with a blow to the head, halibut large enough to be dangerous on deck cannot.

Keith’s onboard halibut weapon, a.410 gauge, single-shot, break action, 18 ½ inch barrel, loaded with birdshot, it represents the minimalist’s shotgun: a danger to fish but not to the boat.

Larry held the struggling fish with his rod.  I put on my noise-cancelling muffs and protected Bethany’s ears with my hands while we watched.  Keith gaffed the fish with one hand and administered the coup de grace with the other.

When finally aboard we gasped at the size

(Keith has brought in halibut more than 6 times bigger.)

We went back to fishing.  Bethany hooked one well, and reeled till she fatigued.  I took over and brought in a respectable 31” fish.

I seized the moment when the rod tip jiggled.  Working the reel I brought the fish up by degrees.  A couple of times it dove, and I quit trying to work the line flying out against the drag.  I brought in 50 feet before I had to rest for the first time, holding the rod with my right hand while blood flow returned to my left.  As the fish ascended my rest stops grew more frequent, each a mandatory 8 count.

Bethany asked, “What are you doing?”

“Regenerating my creatine phosophokinase,” I answered.  “It takes 8 seconds.”

I worked the reel crank by crank and my rests grew closer together.  Finally I asked Bethany to take over.

Neither of us at our age have hand stamina adequate for bringing in a big fish from a long way off, and we have learned how to relay.

Bethany brought the fish close enough to the surface for Keith to gaff.  A respectable fish, about 50 pounds coming out of the water, too small to shoot but big enough to club.

With 4 halibut in the boat, we started back to Homer.  Larry’s left hand cramped, and I volunteered to massage it.

“Why does it do that?” he asked.

“It cramps because it’s fatigued,” I said, and I could tell he wanted more of an answer.  “You ran out of creatine phosphokinase, the enzyme that keeps the muscle from cramping.”

The cramps came from the forearm muscles which provide the main grip strength as well as from the hand’s own muscles that let us squeeze our fingers together.

It wasn’t really medical care; I learned more sophisticated massage techniques in undergrad dorm rooms.  Still, I made him feel better.

In Homer, we took pictures.   I had to get Bethany to help me raise our fish, even though it was smaller than Larry’s.

halibut photo 2019 26May

Larry hoisted his fish and his hand fatigued and cramped again.  I helped again with massage and showed him a few simple exercises.

Halibut x4 2019 26May

How can you tell the south Alaska winter is over?

May 21, 2019

These could be signs of the spring

The grass coming up soft and green

And though you look twice

You’ll find no piles of ice

And moose moms get protective and mean.

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, western Nebraska and Canada. I have now returned to southern Alaska. Any identifiable patient information has been used with permission.

In the lower 48 people look for signs of spring in the first robin or crocus, or the appearance of morel mushrooms in the woods, or the sound of wild turkeys gobbling.

With Alaska’s furthest north point, Utqiavik (formerly Barrow) as far north from here as Windsor, Ontario is from Atlanta, people look for different things to show that winter ended.  In Utqiavik, for example, they look for the last sunset.

How do you know that the southern Alaska spring arrived?

Wearing long underwear makes you overheat on your way to work.

No ice on your windshield in the morning.

The last snow pile at the edge of the parking lot melts.

You hear reliable rumors of King salmon swimming upstream in the Kasilof.

You can tell male moose from female moose:  the bulls have their first antler buds covered in velvet, and you can see the fetuses kicking the sides of the females.

Clouds of mosquitoes come after you when you get out of the car.

The bait fish, the hooligan and the needle fish, go into spawning frenzy, the sea gulls dive head first from 30 feet up, and the King salmon you catch in Cook Inlet looks like he’s been sitting at the football team’s training table.  Because he’s been eating hooligan and needlefish.

You don’t see floating cakes of ice in the rivers, estuaries, or bays.

You don’t gasp at produce prices at the grocery store.

Traffic on the Alaska Route 1 gets louder and louder, and the people who live here all winter complain about the RV traffic.

The snow birds return with Arizona tans and Mexico t-shirts.

The tourist attractions on Homer Spit open up.

If your recipe says to let something set up overnight you have to start before sunset and let it go after sunrise.

Nights don’t get dark enough to see stars, twilight lasts all night, which isn’t very long.

You have to start worrying about bears.

Of hearing aids and tremors.

May 15, 2019

She didn’t hear well, I suppose

For the wax that clogged the holes

Of the aids for her hearing

With the brush I went clearing

And she left with so rosy a glow.

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, western Nebraska and Canada. I have now returned to southern Alaska. Any identifiable patient information has been used with permission.

I won’t write about what the patient came in for, because I didn’t ask for or get permission to write about that, but I asked for and received the go ahead to write about the rest.

I followed my usual approach and didn’t interrupt until she had told her story.  Then I started to  question.  At the third question, she furrowed her brows, apologized for not understanding me as her hearing aids weren’t working.

Despite new batteries, they didn’t help at all.  After her appointment, her husband would come back from fishing and they’d spend the rest of the afternoon driving to the Costco in Anchorage.

Let me have a look, I said.

I hated near sightedness as a kid, but now I find it a gift: to see very small things as I push 70, all I have to do is take off my glasses.

I stepped out of the exam room and retrieved my hearing aid case and its tiny tool.  I slipped off the tulips, the part that goes into the ear.  The ear wax packing the miniscule opening came out easily with the plastic thread, about the same diameter as fishing leader.  With my hearing aid brush I swept out the debris clogging the microphone holes and handed the hearing aids back to the patient.

I drew great satisfaction from her smile, even more so because I knew she wouldn’t be facing 7 hours on hazardous roads.

She explained that her tremor kept her from doing things like cleaning her hearing aids.

I confirmed I saw her hands shaking while I was working on her hearing aids, despite the fact that she kept her left hand hidden.

Then I did my Parkinson’s diagnostic test:  I held her hands, encouraged her to relax and I listened.  As she relaxed, the tremor in her left hand got worse and the muscle in her right hand, between her thumb and forefinger, started to quiver.

I asked my usual Parkinson’s questions: loss of balance and sense of smell, shrinking handwriting; she answered yes to some and no to others.

I diagnosed Parkinson’s disease.  Treatment helps symptoms, I said, but that medication doesn’t slow the disease progression.

Since her tremor started decades ago, she’d seen lots of docs, including neurologists, all of whom agreed she didn’t have Parkinson’s but benign familial tremor.

Perhaps she had that, too, but I knew for sure today she had Parkinson’s and I could probably help her.

She confirmed her current medications didn’t help much, if at all.

We set up a plan to start Parkinson’s medications at very low dose.  As I’ll be leaving in less than a month, some other doc will have the pleasure of seeing her blossom with Sinemet, the later the tedious but rewarding process of deprescribing several medications.

But I had a great time fixing her hearing aids.

Lunch at a senior center, this time as a senior.

May 15, 2019

We have now come around to that age

Where we work, but not for the wage

While the winds went to whirling

We set off for Sterling

A decision we found rather sage.

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, western Nebraska and Canada. I have now returned to southern Alaska. Any identifiable patient information has been used with permission.

With terrible weather forecast for Cook Inlet, Friday we avoided fishing and went to the Senior Center in Sterling; we had heard they serve exception burgers on alternate Fridays.

We found two raffles, one for a very large, beautiful quilt, and one for a .22 rifle.  Both of us bought tickets and neither complained about gender specificity. Neither of us expect to win the raffle, both regard the purchase of the ticket as a donation, and neither could predict what we’d do if we did win.

About 30 people occupied the hall, including a surprising number of children exhibiting varying degrees of truculence sitting with their apparent grandparents.

Neither of us had ever been to a Senior Center as a Senior before.  But now we have reached the age where we can benefit from Senior programs.

We both had our burgers with caramelized onions, sautéed mushrooms, onion rings, and French fries with a side of beef chili and chips.  The grand total, $15 for the two of us, stands out as a Best Buy for an Alaskan lunch out.

Around the room I could diagnose emphysema, depression, alcoholism, and Parkinson’s with certainty, along with probable diabetes, hypertension, heart attacks, and stroke.

The day before I had 3 patients, all male, and none more than 10 months different in age from me.  The number of diagnoses I had in common with them gave me credibility, and I established rapport by talking about fishing.  I continue to learn from my patients.

I have cared for a surprising number of fishing guides and commercial fisherman, at varying stages of retiring, from a week before the sale of a business to a month after, through the pain of the first season not fishing, to never wanting to quit.

Most, not all, people in my age bracket who still work do so because they want to.  Between savings, Social Security, inheritances, and cashing out businesses, they have enough money to live comfortably till it runs out.

Some don’t.  Alcohol, tobacco, drugs, gambling, and divorce account for much financial insecurity; but those who arrive at old age with money problems have dealt with such problems most of their lives.

The few who have experienced long periods of leisure seem to do the best as seniors.  They know how to spend their time and their money.

 

 

 

 

 

 

 

Perfect people don’t come to see me.

May 1, 2019

When it comes to the way patients flow,
You could call this gig a bit slow.
But the patients expressed
They’ve been pretty impressed
At the warmth that I can show.

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, western Nebraska and Canada. I have now returned to southern Alaska. Any identifiable patient information has been used with permission.

I currently deal with low patient flow on a daily basis. Yesterday I had, for the second time, 5 patients in one day; all the other days have gone more slowly. Yet with 5 patients, each scheduled for ½ hour appointments, I kept busy. My electronic inbox never gets to empty. I review lab work and incoming consultation results. In fact, my in box would keep me busy for about 2 hours a day whether or not I saw patients. Thus the electronic version of paperwork flows so fast that it has acquired a life of its own.
Still I have a good amount of time to spend with each patient. I impressed each one so far with my patience. I nod, I listen, I take notes. I get to ask the patient their agenda. The vast majority have been over the age of 70; the youngest so far this week was 48.
But I interrupted one patient. Within 2 minutes, I knew my trouble following his story came from his shifting focus. The numbers in his narrative didn’t add up. After a while I asked if he were having trouble focusing, which he was. Eventually, that one piece of information, more than any data from the telling, gave me the diagnosis.
One patient, who gave me permission to write this, has ankylosing spondylitis, a disease I myself have struggled with since 1967 (or maybe 1963). The best I could do during that visit came down to running a chronic pain support group with two people. We turned out to have a lot in common.
Addicts lie. This truth comes so consistently that, when I find a liar, I look for an addiction. However fun and charming the addict, their words cannot be trusted, especially when it comes to what drugs they use. I have not yet found a way to figure out when an addict stops lying.
But I listen to the addicts and alcoholics as patiently as I listen to the overeaters and the smokers. Perfect people do not come to see me. Everyone who brings illness through the front door comes with a back story of drama and irony, and I have the time here to dig for the patient’s agenda.
The patient’s agenda always wins. Asking what they want in 5 or 10 years uncovers that agenda better than anything else, but does not do so perfectly. Some people don’t know what they want. But asking what they want makes them think.

Health choices could obviate doctors. Mostly.

April 16, 2019

The winter left gravel and sand

On the roads all over the land

Back home the snow’s pelting

In the north, here, it’s melting.

I’d call the Alaska spring grand.

 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, western Nebraska and Canada.  I have now returned to southern Alaska.  Any identifiable patient information has been used with permission.

I ran into a patient last week not much different in age than myself, who gave me permission to write more about his case than I have.

Every doctor should tell every patient 8 things (not necessarily at every visit): nicotine, caffeine, alcohol, diet, exercise, sleep, seatbelts, and marijuana.  Most of that advice goes unheeded; docs work with people living in the real world making real decisions.  If people did what they know they should, 3 out of 4 physicians would be out of a job. 

This patient, however, has lived his life as an example of a healthy life style.  He loves his wife, he loves  his work.

The medical part of the visit did not last long, dealing mostly with the inevitable consequences of living a half-dozen decades on a planet with gravity.  We had the chance to chat.

He manages dozens of workers in a handful of departments.  I made the comment that I love my work and I don’t have leadership skills.  He told me that’s exactly that kind of person he wants as a department head: the ones who don’t think they’re leaders can make the best leaders.

As the conversation progressed I could tell that I’d love having him as a boss.  Though I aim now at a place on the organizational chart at the same level as the janitor, I could see that with his kind of encouragement I could rise in an organization, and probably love it. 

I have to consider the possibility that lots of people have happy, healthy lives, and thus do not need to see the doctor often.

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Snow melt left all the local paved surfaces covered with sand.  Cars kicked up dust till the street sweepers swept away winter’s detritus, which made the town dusty for about 10 days. 

Two weeks ago, coming back from fishing, a machine on the highway raised a column of dust that could have guided the Children of Israel.

Now most paved surfaces, including sidewalks, have been swept.  Parking lots have lost tons of sand and pea gravel, but almost all have a shrinking snow pile at the edge leaving a thin trickle of melt water draining to the gutter.  When gone, they leave behind more sand and gravel, and the flotsam of winter: hats, gloves, and socks.  It’s spring in Alaska, daytime temps don’t go over 45, freezing nights leave a coat of ice on vehicular windows. 

And back home, in Iowa, they’re still waiting for the last snow fall.