Archive for the ‘Uncategorized’ Category

Fisherfolk and forest fires.

July 20, 2017

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

The stuff that makes you wheeze, cough and choke

This great conflagration

Caused evacuation

And perhaps even brought on a stroke.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

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

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

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

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

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

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

 

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

July 13, 2017

The thought that gives me a scare

Has do to with a grizzly bear

For he’s big and he’s massive

And pretty aggressive

And, out here, not terribly rare.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to travel and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent US assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Some people survive events far beyond the usual human experience.

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

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

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

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

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

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

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

-*-*-*

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

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

*_*_*_

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

Locks on the Clothes, Keys on the Shoelace: the dress of a millwright.

July 9, 2017

The millwrights has many a key

For the mill cuts up many a tree

On the machine go the locks

Preventing visits to docs

And keeping the workplace accident-free

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Thursday I took care of 17 patients. One pediatric patient required all my patience, skill, and accumulated experience to get the job done without alienating the kid.  The oldest patients barely qualified as septuagenarians.

I wrote a lot of prescriptions for blood pressure drugs.

I used my deep-breathing techniques on three patients to bring blood pressures into the acceptable range.

Though only 15% of Canadians smoke, the nicotine addicted comprised more than half my patients.

I wrote several back-to-work slips, all employees in the timber industry.

I cared for even more millwrights and former millwrights. Changing logs into useable products involves a lot of dangerous machinery, and the people who fix the machinery come in loaded with padlocks on their clothing.  They lock a machine before they work on it, to make sure it won’t start accidentally.  Spare keys get carried where they can’t get lost, such as tied into shoe laces.  During the work day, a “whistle” signals a need for a millwright.

One of my patients in frustration said, “Can you give us a referral to see a specialist we can actually see?’ and we laughed after I asked for and received permission to use the quote in my blog. While I know my way around the human body, and most of the things that go wrong with it, I don’t know the local medical community.  Yet the permanent doctors trained near here, and know the consultants personally.

There’s also a province-wide network providing phone-in advice for docs . The consultants get paid on a fee-for-service basis; the patient has a unique identifying number, and the doc has a bunch of unique numbers (I have 8), one of which is the right one to use.  Computer algorithms coordinate compensation.

Lower blood pressure with deep breathing

July 5, 2017

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

But when the smoker lights the first fag

And breathes deep and slow

Though the smoke is the foe

They’re champs at that very first drag.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

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

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

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

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

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

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

+=+=+=

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

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

June 25, 2017

They come in, right off the street

The problem it seems, is the feet

And then when the pain

Makes them complain

Orthotics just can’t be beat.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

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

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

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

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

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

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

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

 

Dislocated thumbs and warmth in the ER

June 24, 2017

To the ER the injuries come,

So I just took hold of the thumb

Yes, dislocated

But a technique underrated

Includes no drugs to make the hand numb

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

Over the years I’ve learned at least 8 different ways to put a dislocated shoulder back into place (medicalese: reduce the subluxation).   My favorite remains the one I learned in the parking lot of the hospital on my last day of residency.  I met one of the emergency docs coming in as I was going out for the last time.  He told me he’d learned the technique that involved no drugs, bandages, tape, buckets of sand, or force, and he showed it to me.  I use it to this day.

It failed only once, when in another clinic in another city a very muscular young man suffered a dislocated shoulder in the course of an electrical injury.

Last night, on call, for the first time in my career I faced a patient with a dislocated thumb (the patient gave permission to include a good deal more information than I have). I looked at the x-ray, I reviewed the anatomy, and put together a plan.  But I’d never done one before so I felt I should at least speak with someone with more experience before I tried it.  I put out a call to a consultant orthopedist and I waited.

And I waited.

One of my colleagues who had done several of the procedures, just back from an ambulance run came striding through. I told him the plan, and he gave me the nod.

I had the patient give me the thumbs up sign. I grasped the digit, and we started to chat.  As the patient relaxed, I took the weight of the hand, and, eventually, the arm.  After 5 minutes, supporting the forearm with my other hand, I let go.  Using patience and gravity, the thumb had slid back into place, with no drugs, no violence, and no clunk.

Just the way I like it.

_*_*_*

Injured people rarely come into the ER alone. Some of my patients have problems so difficult to look at that you wouldn’t see them in a horror movie.   The visual impact can jar friends and relatives into free displays of affection.  But during a recent night on call, I witnessed a kiss so astounding that the warmth flooded the ER and so memorable I had to comment on it.  I kept doing what I had to do, thinking all the while that so much love must make a difference in the healing process.

 

A small town is a complex system

June 15, 2017

There are stories, and then there are tales

There are successes, then there are fails

I can say how it went

After the event

But I cannot disclose the details.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

 

I don’t like big cities, I never have. I grew up in Denver, and I can remember thinking at age 8 that city held too many people for my comfort.  After I left home I kept moving to smaller and smaller towns until Bethany and I found ourselves on the Acoma Reservation in New Mexico, in a settlement of about 75, attached to the hospital.  Seeing a stranger would come up as a topic of conversation for a week.

When we moved to Sioux City we found ourselves inside a city limits holding 5 small towns with pockets of wilderness that contained deer, turkey, and mountain lions. The nearest buffalo herd roamed a river bottom 30 miles away, and once a wayward moose wandered through the county.

So I really enjoy this small town. It has a good grocery store and a wonderful recreation center.  Everyone knows everyone.  The first graders walk themselves to school.  Drivers on the highway, like most Canadian drivers, stop to let pedestrians cross.

Wilderness lives hard by civilization here. Enough black bear try to sort through garbage that dumpsters lock, and have signs proclaiming A FED BEAR IS A DEAD BEAR.  I believe the story (though I haven’t verified it) that when the fence around the dump got electrified, 50 grizzlies came into town and had to be relocated.

This town qualifies as a complex system in the mathematical sense of the word: the diverse components connect, interact, and can adapt.  A person could spend an academic career studying complex systems, or even one complex system, but, in brief, everything is connected to everything.  Changing one element changes every other element in a non-linear fashion.

I can’t talk about details of the case, but at the end it involved neighbors, friends, colleagues, and my wife. In many ways a test, with drama and irony it introduced Bethany and me to the community.

The aftereffects still ripple through the social fabric here. People recognize Bethany through a friend of a friend.  People introduce themselves as friends or relatives of those with close involvement.

But the real health impact on the community will come 21 days after the event itself. For some it will bring healing, for others, illness.

When good algorithms fail

June 7, 2017

The thyroid’s a wonderful gland

And if everything goes just as planned

When we get the right number

With good conscience we slumber

But there’s another approach to be scanned.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed.  I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I do a lot of lab tests and x-rays, and I interpret results in the human context. Every result pertains to a person in a psycho-social environment, a factor in a complex system where everything is related to everything, and you can’t change one thing without having an effect on everything else.  Thus the popular medical saying, “We don’t treat lab tests, we treat people.”

Hypothyroidism, where the disease stems from an underactive thyroid, a very important H-shaped gland that sits at the base of the front of the neck, stands as an exception to that truism. We treat numbers.  If we get a high thyroid stimulating hormone (TSH) value, we give a small dose of levothyroxine, T4, the same as thyroid hormone, escalating the dose by six week intervals until reaching a normal value two tests in a row.

(The higher the TSH, the more the patient needs thyroid replacement; it represents the brain’s plea to the thyroid gland for more hormone.)

The approach works well for more than 95% of the people with hypothyroidism.

The problem arises in that small segment of the population that doesn’t convert levothyroxine (a core with 4 iodines attached) to its more active degradation product, triidothyronine or T3 (the same core but with only 3 iodines). Because each T3 is worth 6 T4s.

I explained all this to a patient two days ago, who gave me permission to write what I have.

Most people with lazy thyroid glands have symptoms that can include fatigue, depression, constipation, aching muscles, cold intolerance, mental slowing, and difficulty losing weight. And the vast majority feel normal when the TSH creeps under 3.5.

But a very few patients still don’t feel right, and microscopic doses of Cytomel (the trade name for T3) can make some, not all, feel much better.

I wouldn’t know about this if my sister’s very good endocrinologist hadn’t inspired me to read further.

The problem arises that such methodology verges on what many mainstream doctors call “fringe medicine,” because of the actions of a very small number of unscrupulous doctors. I try to keep a low profile, and I ran the case by two of my colleagues.  One expressed mild surprise, the other, as it turns out, uses the same approach

 

Reflections on medical frauds

May 8, 2017

The system is inherently flawed

They want me to sign and to nod

They have no excuse

It’s all billing abuse

And I’ll say to their face, “You’re a fraud.”

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

Sunday I visited a web site that promised to cure my tinnitus. It had all the marks of snake-oil fraud: heavy reliance on testimonials, repeated themes that the establishment didn’t want the product to succeed, recounting hard-to-believe medical horror stories for those that relied on established medical practice, and at the end the assertion that the narrator didn’t want to make money, he only wanted to do good for the world but mainstreamers would soon make him take down his website because of jealousy over his success.  Those tools exist because they work, and they nearly worked on me.  I wanted to believe.  But I knew if the narrator really just wanted to help people, he would have made the audio download available for nothing, and relied on contributions to keep the website up.

Towards the end of the video the phone rang. I listened to the robot,  pressed one, and told the live operator, “Your prerecorded announcement said I got the call because I’d responded to a TV back brace commercial.  Is that right?”

“Yeah.”

“How can that be? I don’t have a television.”

The line went dead.

This morning when I dove into my IN box  I found 4 faxes from a physical therapy operation in a nearby town, wanting me to sign off on very general orders for patients that I didn’t know and certainly hadn’t examined. I called the number at the bottom of the sheet, and spoke with a secretary who explained that the firm had a direct access program.  I tried to explain, in turn, that I could not in good conscience sign off on a patient with whom I had had no contact.  But as Mark Twain observed, it is difficult to get people to understand if their jobs depend on them not understanding.  I turned the papers over to our clinic manager.

Yet I also got a similar order sheet for medical supplies, and I checked with the staff; the doc whose place I’m holding indeed orders those supplies yearly, and I signed.

Our country has an enormous amount of medical fraud; vendors interested more in profit than patients buy a lot of late-night TV commercial time, and some people call in to get scooters and other durable medical goods. Over the years I had a lot of requests to sign off on knee, back, elbow and shoulder braces, none were needed.

Yet a few vendors offer diabetic supplies at greatly reduced cost. So I can’t just shred all the requests.  I have to read each one.  After all, the fraudsters only copy successful business models.

 

The thrills of cerumen and B12 deficiency

April 23, 2017

Real flu has cough, fever, and ache

And I know just the pill you can take

And then there’s the test,

It’s good but not best

But a decision it sure helps me make.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I had a good week in Clarinda.

Orientation on the new job went well; I found it well-organized and well-planned.

The facility not only assigned me a scribe but also a cracker-jack Electronic Medical Record superuser to train me on the 14th new EMR I’ve learned in the last 28 months.

Recognizing the problems of learning a new system, my patients have come no more often than every ½ hour.

Thursday morning went well; I had the immediate gratification of curing the first patient by removing ear wax and the second with osteopathic manipulation.   Close to noon I received lab results on tests ordered earlier in the week, including three vitamin B12 levels.  Two borderline numbers (between 211 and 400) require further testing, and one came in frankly low, less than half the lower limit of normal.  That bit of information made my day; I can save the patient’s life with a simple injection once a week for 12 weeks, then once a month.

Bethany met me for lunch in the hospital cafeteria: well-prepared, healthy food at insanely low prices. I told about how I found my morning not only gratifying but satisfying.

Influenza dominated the afternoon. We have the clinical experience to predict that the annual flu epidemic starts in the north and works its way south, with 90% of the cases in any one location occurring in the course of 3 weeks.  I enjoy taking care of influenza; we have a clear-cut, good but not perfect, lab test and two effective drugs.  The older the patient, the more likely my prescription will prevent death.  Most of my patients here are over the age of 70 with several in their 90s.

The problem with taking care of old people is that I don’t get enough time to talk to them. I could easily spend a morning or afternoon just listening to one patient.  A person can’t get to advanced age without acquiring a large stock of really great stories.

Thanks to a light patient load and a scribe, I finished at 6:00PM. I walked out of the hospital at sunset, ten minutes across dry winter grass and quiet back streets.  We decided to drive back to Sioux City and our own wonderful bed.  We packed the car in less than 20 minutes.  The sky darkened as we traversed two-lane county roads through the rolling hills and farm country. We detoured to Trader Joe’s in Omaha, but missed a turnoff, adding an hour to the trip.