Archive for the ‘Uncategorized’ Category

Harrowing transfers

January 14, 2018

It’s the time of year for the flu

If it’s that, we know what to do

But in transferring out

We have without doubt

The stressors come out of the blue.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

With bad weather promised in the forecast, I decided to drive to work the evening before rather than the morning of. Fog shut down visibility and I crept the last few miles into town and hotel to await the impending major winter storm.

Overnight the temps plummeted to double negative digits, and the wind rattled the windows. I awoke to a scene of a blowing snow, but the worst of the wind had passed and the gusts stayed under 40 miles per hour.

Not surprisingly, clinic load dropped with the mercury. Through the day I cared for people with the problems of abdominal pain, a cold, a rash, another cold, the flu, a cough, another cold, ankle pain, yet another cold, and an irritated eye.  Two of the patients spoke Spanish; one of them first spoke an indigenous dialect before he started to learn Spanish at 15, thus making us equally Hispanic.

At the end of the day one of the permanent docs and I went to the Mexican restaurant. We talked a lot  about hunting and Alaska and the pragmatic parts of medical practice.

I had almost 45 seconds at the hotel before the call summoned me back to the ER to care for another person with a respiratory infection.

I took care of 3 more patients before midnight, one psychiatric and two respiratory. I did not ask for permission to write about any of them.

But I can write about the problems inherent in rural practice. Small hospitals lack the resources to deal with life-threatening problems.  Whether in Iowa, Canada, or Alaska, patient transfers can be the most harrowing part of the job: you don’t have to send well patients to referral centers.

Here I have to do a complete history and physical, just as if I intended hospitalization. I get the basic labs, and, if necessary, x-rays.  I ask the nurses where to best send the patient.

Sometimes neither nearest nor best-equipped means the same as best.

Then I make the first call. Sometimes a secure video link, much like Skype, opens up.  I generally have to go through a nurse to get to the doctor, who has final authority to say, Yes or No to the transfer.

Depending on the context, ambulance and/or law enforcement personnel need to be enlisted.

Then the harrowing wait begins. The helicopter, airplane or ambulance never shows until I have hit the outskirts of emotional exhaustion.

When the patient leaves, I start keyboarding my history and physical into the computer as fast as I can. I hand the printed copy to the nurse with the request to fax it to the accepting physician.

Then I dictate the same information into the dictation system.

I got back to the hotel shortly after midnight, too wound up to sleep. I studied for an hour and a half.  I slept surprisingly well before going back to the clinic to discuss legal threats with the manager.

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The last week of the year

January 5, 2018

The Canadians were boxing that day

The 26th is a time that they play

But I took the call

Which was not rushed at all

But was long. What can I say?

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

Much has happened in the last week.

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

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

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

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

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

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

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

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

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

 

A Tale of Two ER Patients

December 27, 2017

The blood came gush from the nose

Staining the floor and the clothes

But a Merocel pack

Slid from front to the back

Brought a stop to the flood, I suppose.

 

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

A tale of 2 ER patients.

I find the process of transferring patients out daunting and frustrating. The remoteness of the community demands stewardship of the two ambulances with their crews.  Thus, when possible, I send  patients to Prince George via POV (privately owned vehicle).

Even then, the process of stabilize-and-transfer can involve an hour or two of ER time when I get to chat with a patient.

I got to talk with a chef, who gave me permission to write a good deal more than I have. His camp, with 120 workers, employs three cooks, each responsible for one meal a day.  We had a great time talking about gravy; we agreed that corn starch beats flour for thickener, and that a good broth or stock means more to the sauce than the drippings.

*-*-*-

 

I gave a different ER patient the reverse of my usual dietary advice. Eat three scoops of premium ice cream at bed time, I told her.  Don’t drink water, always make sure your beverage has calories, especially high fructose corn sweetener.  I described how the Iowa beef industry uses it to accelerate fat gain in cattle.   I told her not to eat anything without gravy, mayo, or a sauce.

At the end, I said, “I write a blog. I won’t mention name, diagnosis, or age, but I’d like to write about the eating plan I gave you, the opposite of what I usually give out, how poison for one person is life-saving for another.”

She waved her hand and said, “You can use my name if you like.”

 

*-*-*-

During my IHS time in New Mexico, I saw 2 or 3 major nose bleeds a week for 18 months.  In that time, I became skilled at packing the front part of the nose to stop the bleeding.  Most times I could get the stanch the flow, and when I couldn’t, I knew what to do to get the patient to specialist care.

But since then the nose bleeds I’ve seen were simple, easy to stop temporarily followed immediately by a touch with a silver nitrate stick for permanent resolution. .

But the problem of serious epistaxis (bleeding from the nose) relies heavily on equipment, and the equipment has changed in the last 30 years. Our hospital has specialized catheters with inflatable balloons (the Rapid Rhino), and sponges made of material that promotes clotting (Merocel).  We also have tranexemic acid, unknown in the 20th century

For the time frame involved, I’ve seen more than my share of complicated nosebleeds this trip. I discovered that the closest Ears, Nose, Throat specialist doesn’t take call, and that most of the ER docs cheerfully confer by phone.

Croup treatment has and hasn’t changed

December 21, 2017

With a cough like the bark of a seal
And the kiddy so good doesn’t feel
There’s no way to avoid
A dose of steroid
Croup must be treated with zeal.


Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. A month in the Arctic followed a month in Iowa followed 3 months in British Columbia, to which we have returned. Any identifiable patient information has been included with permission.
I had cause to contemplate how things do and don’t change in medicine. Consider, for example, croup. If a virus swells a child’s narrow airway, a barking cough, much like a seal asking for a fish, follows. Death can ensue if the airway narrows to the point of closing, or if the child stops breathing out of exhaustion.
The pediatric ward in the hospital where I did my residency had two outdated features for treating croup when I arrived.
One consisted of a tiled room that could be filled with water vapor; a large cloud chamber that could sleep 8. During my tenure its only use was storage.
But the spacious balcony on the other side of the nurses’ station told a different story. It had sliding glass doors and space for 6 cribs. In a bad croup year, the nurses bundled the children up, to sleep with their faces uncovered in the cold, dry Wyoming air.
It worked for most of the kids, and I still recommend that strategy, saying, “Now if the spasm of croup doesn’t clear in 3 breaths you’re already headed to the ER.”
Treatments have come and gone and come back. Antibiotics, we found, did no good. Theophylline (a close cousin of caffeine, and found in pharmacologic amounts in chocolate) helped, but not much, and had a lot of side effects so has since been completely displaced by the albuterol (in Canada, salbutamol) updraft.
Every winter, during the peak croup season, I’d ask my pediatrician friends if we’d gotten anything new for croup, and every winter they’d shake their heads.
We used to use inhaled adrenaline (also called epinephrine). It has come and gone in five year cycles. A year and a half ago I thought for sure that I’d never use it again when I heard a study showed it did no better than inhaling saline (salt water).
We used steroids a lot and stopped for a while in the 90s, started again just before the millennium, and continue to this day. Controversy remains regarding dose, and method of administration.
But croup has changed. The really, really bad version, where the epiglottis (the flap valve between the airway and the swallow tube) swells has disappeared with modern immunizations for diphtheria and Hemophilus influenza. And with the decreasing smoking rates we don’t see nearly as much as we used to.
I had cause to research croup treatment recently, finding, to my surprise, that all my internet sources recommend inhaled epinephrine and steroids. Just like 1982.

Why the nicotine patch fails, and what to do about it.

December 17, 2017

The smoker should take part of a straw

Through which, when breathing, should draw

For the smoking cessation

It bring relaxation

And that, with the patch, is the flaw.

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

 

I hate tobacco with a passion which I restrain to as to not alienate patients. I ask people, on a scale of 1 to 10, how ready they are to quit.  If they say 1 or 10 I move to another topic.  If they say anything else, I ask them to tell me why they aren’t LESS ready to quit, and to name the best three things about smoking.

Smokers most commonly say “stress relief” as the best thing about smoking. I used to argue, pointing out that smokers smoking have the same level of stress as non-smokers at baseline; the stress the patient felt, I would say, comes down to nicotine withdrawal.

That approach didn’t help anyone quit; if anything it hardened the person’s commitment to death by tobacco.

Recently, I have started to point out that if a person wants stress relief, the deep breathing exercise that every smoker has mastered brings half the stress relief of smoking. Inhale like you’re getting the best drag of the day, I say, and your stress level will go down.

(Recently the FDA approved a device to treat high blood pressure.   Really an app, it gets people to slow their breathing.)

I think the nicotine patch fails so often because the people don’t get the stress relief of deep breathing.

Today, a patient who had already figured out that strategy announced he planned to get some straws and to breathe through, to give him something to do with his hands.

And, just like that, within an hour I had two more patients intending to quit smoking.

I advised both to get a soda straw, cut it in half and carry the half where they carry their cigarettes. And to breathe through the straw as if smoking a cigarette.

This simple, brilliant technique will answer the habit strength question, help with stress management, give the person something to do with their hands which also includes the mouth, and give the person much the same velocity of air as breathing in through a lighted cigarette.

 

The First week back in Canada

December 10, 2017

Oh, the joys of that 12th vitamin B

A low makes me dance round in glee

For without scalpel or knife

I can save someone’s life

And the med costs a very small fee.

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

Though scheduled for orientation on Friday, I remembered a good deal of the electronic medical record (EMR), and started in with walk-in patients at 10:00AM. By the end of the day, I’d attended 11 people, as good as my best 8 hour clinic day during my most recent month in Alaska.  Patient flow goes very well here, documentation comes easily.

I carry the title locum tenens, which means that I’m a substitute or a temp, and only the night before did my name fall onto the schedule. Yet I knew 4 of the patients I took care of.

Monday started a very good week. I enjoy patient care, but I know that seeing too many patients in too short a time brings too much stress.  I saw a decent number of patients, rarely ran more than 10 minutes late, got lunch every day, and finished my documentation before 5:30 PM.

Filling in for two docs, at one point I had more than a thousand lab results to sign off.

An unusual percentage of the alcoholics I saw recognized the problem, and an unusual number of smokers had already decided to quit. Although, in fairness, an almost identical number of smokers had no interest in stopping.

I took call on Thursday to Friday morning. I slept poorly as much from the emergency at 3:00AM as from zigzagging time zones.

Friday more than half my patients represented repeat business. The clerical staff informed me that when people learned of my impending return, they waited to schedule with me.

Three of those patients had vitamin B12 deficiency. One of them gave me permission to write about the thrill I get from running the right test at the right time and finding that diagnosis.  I don’t often get to save a patient’s life, and, with B12 deficiency, I get to do it for pennies a day.

B12 deficiency most commonly presents as fatigue. In the past I started the investigation on the basis of depression, anemia, numbness, gait disturbance, erectile dysfunction, ADHD, and dementia.

In other clinics, management has discouraged me from ordering B12 assays in the Emergency Room or Urgent Care contexts. Yet, finding a result in my lab queue with that critical L beside the number brings me disproportionate joy and gives me a goofy grin for the rest of the day.

Which is why I prefer positions where vitamin B12 measurements are appropriate.

At the end of another Arctic assignment

November 27, 2017

After the lessons not learned

And the good advice has been spurned

Sometimes slow, rarely quick,

People get sick,

I do my best though the bridges are burned.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I just finished a month in the Arctic.  Any identifiable patient information has been included with permission.

Aside from well child checks, perfect people do not come to see me. Most of my patients have made a lot of decisions they regret, and, whether they realize it or not, when the consequences add up they get ill.

In my years in Community Health I learned that schizophrenia, bipolar (formerly called manic-depression), and substance abuse overlap so much as to be indistinguishable.

Sometimes patients are difficult to talk to. Schizophrenia, for example, can rob the face of expression and make speech slow and monotonous; Parkinson’s disease can do the same thing.

Alcoholics, marijuana abusers, smokers, meth heads, and narcotics addicts get sick more often and more severely than those who lead orderly, substance-free lives. Leaving the start line with mental illness that hampers learning from experience gets compounded with substances that do the same thing.

I do my best to focus on my job: fixing what can be fixed and preventing what can be prevented. Bringing up a person’s past mistakes brings nothing good to a medical visit.

Every day I attend patients in desperate circumstances. I do my best to listen to what they say, and what they don’t say.

When I start to fall into the trap of judging people who have come to the inevitable consequences of reality avoidance, I remember the many mentally ill I’ve cared for who tried so hard to stop the voices in the heads. Because it’s easier not to judge if the person has a diagnosis.

I sit and talk to someone who has burned a lot of bridges, brain cells, and assets using recreational chemicals, and I do my best to tease out the story from a wandering narrative. I nod and look into the face of devastated youth and beauty.  I listen to speech patterns that some find annoying, and when the patient finishes talking I ask the right questions.

I do my best to get them to the correct medicine. Often the patient requests drugs that will make their problems worse, not better, and I explain the rationale for avoiding them.  Mostly they follow the logic, sometimes they don’t.

A lot of the people here have asked me if I’m staying. I don’t plan to, but I’d like to come back.

Inevitably, I don’t get along with some people.

But then, perfect people don’t come to see me.

 

 

A procedure I couldn’t talk the patient out of

October 29, 2017

I looked down at the big toe

To see how the nail did grow

It sure wasn’t right

And it hurt day and night

So I fixed it, but not for the dough.

 

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

Medical school and residency merely start the process of lifelong learning required of my profession.

In residency, I saw one ingrown toenail removal before I did three under supervision. In the Indian Health Service, a podiatrist said, “This is the procedure that’s going to put your kids through college!” and gave me some tips on speed.  In the 90’s I did quite a few, but by the time the century turned, despite a large financial motivation to the contrary, I figured out how to get the patient taken care of without shedding blood.  A bit of cotton, an orange stick (a wood implement widely used to rearrange cuticles) and a bit of povidone dione (marketed most commonly as Betadine), with patience and about a week, can usually move the flesh away from the nail a millimeter a day.

Over the summer, researching the problem while in Canada, I came across the concept of a nail spreader, which can flatten out a curved nail over the course of several months.

But the patient yesterday (who gave permission to write more than I have) had already tried everything I had to offer, yet the problem persisted.  And I couldn’t talk  the patient out of the procedure.

Finding the right equipment takes up more than half the time of an office surgery when neither the physician nor the nurse knows where anything is.

I got trained to not only take out the nail plate, but scrape away germinal matrix (the tissue that makes the nail) down to the bone with an instrument called a curette, then apply a chemical, phenol, so destructive to human tissue that the nail would, hopefully, never grow back.

We had no curette, and no phenol, and I didn’t mind: less work for me and a good deal less blood loss.  At the end, I used a stick coated with silver nitrate to burn the heaped-up inflammatory tissue growing over the nail.

During the procedure we talked about high school sports (very important in small-town America) and music while outside, the gentle snow fell.

6 afternoon patients and an evening power failure.

October 22, 2017

With a light do you send out a scout

To see what the problem’s about?

For it gets pretty dark

And the prospects are stark

Up here when the power goes out.

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

On my first Friday back in the Arctic, I got to talk with a Native about village life.  After getting through the medical agenda, I asked about fishing.

The village in question right now does it a lot.  And, with freeze up coming, the Natives are working the set nets.  Soon the caribou migration will start.

But the whaling grabbed my attention.  We talked about a village that brought in their entire quota of 10 bowheads last spring; in times past the villagers sometimes had to make do with as few as 4.  In the process, we talked about making the bombs necessary for the complicated harpoon that the Natives use.

***

I had the thrill of making two people better before they left.  One I helped with massage and spinal manipulation, one with an exercise I saw on YouTube.  “YouTube?”  the patient exclaimed, “You mean I could be a doctor from YouTube?”

I said, “You want to learn to put in a chest tube or do a cricothyrotomy?  Go to YouTube.”  And, in fact, you can find instructions on almost any procedure.

***

Still learning, or relearning, the Electronic Medical Record system here, I only had 6 patients scheduled for the day, 2 in the morning and 4 in the afternoon.  I’m just getting the hang of sending the prescription to the pharmacy before the patient leaves, and finishing the remaining documentation later.

The docs here meet with staffers for morning report, much like we did during my time in Barrow (now called Utqiavik).  Shortly before the meeting started, I realized I’d brought the wrong cell phone, the one with no local signal.  Yet, wonder of wonders, I had two bars of service and updated email.  I texted Bethany to not text me on either phone, attributing the miracle to sun spot activity.  She didn’t get the message; I have no idea if solar flares were responsible.

***

We had settled in for the night when the power failed, and moonless Arctic nights have a deep, Stygian darkness.  We have had power failures everywhere we’ve gone, and for the most part we can laugh it off as part of the adventure.  But our all-electric housing has no alternative to combat the cold, and while I searched out flashlights and head lamps (a total of five) I started to worry about making it through the night.  While the hospital has emergency power and we have long underwear, here we lack the cold weather sleeping bags and tents residing comfortably in our basement in Iowa.

The words power outage take on new meaning in an unforgiving climate.

This year’s first Arctic day seeing patients

October 22, 2017

The one forty-five didn’t show

Perhaps the wind and the snow

Made him think twice

About going out on the ice

Where a fall can be the stop of your go
Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic. Any identifiable patient information has been included with permission.

I started in to seeing patients this morning after rounds. The first patient of the day would have presented more difficulties if I didn’t speak Spanish with considerable tolerance for dialectic variation.
I got a chance to write when my 1:45PM patient didn’t show.
In less than 72 hours the weather went from overcast and rainy to snowy, then clear. When snow falls, people become the unwilling slaves to Newton’s 3 laws: A body in motion remains in motion absent external force, a body at rest remains at rest absent external force, and for every action there is an equal and opposite reaction. Friction can conceal those laws from our consciousness, but put dry powder snow onto black ice, and people slip, slide and fall. And then they come to see me.
The real heart of a medical visit, though, lies in evaluating what the illness means to the patient. And each patient so far today arrived with unique circumstances with a fascinating back story.

Consider the overall Alaska picture.  Natives have seen tremendous change, and many have been engulfed by linguistic upheavals.  In the memory of people younger than me were the trips onto the winter sea ice, camping in igloos to hunt seal with harpoons, using dogs to find the holes in the ice where the seal come to breathe.  Most non-Natives moved here from somewhere else, and each one finds themselves in the middle of a personal odyssey.  Of the small number of non-Natives, born here, most have moved around, a lot.  Each move has its own tale of motivations, losses, and gains.

Those, like me, who keep coming back to the 49th state, have their own epics.  This time I’ve found two people I’ve worked with before in other places on the Alaska coast, and a third is soon to arrive.