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Permit, license, insurance, and a contract with the Queen

October 7, 2018

I ended up feeling so keen

For three things, together they mean

I no longer lurk,

But I can come out to work

After my contract I sign with the Queen.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, my 50th High School reunion, and a 4-month assignment in northwest Iowa, I have returned to Canada.  Any identifiable patient information has been included with permission.

Monday morning I strolled over to the clinic, marveling at my first snowfall of the year.

I had submitted my work permit electronically to the College of Physicians and Surgeons of British Columbia (CPSBC), which they required before reactivating my license.

I got my new passwords arranged. I’ve done 18 new electronic medical record (EMR) systems in the last 4 years, and, having been away from this one for the summer, I spent the morning practicing.  Mickey Mouse’s name turns up as an imaginary patient in a surprising number of EMRs, including this one.  I entered the diagnosis of felinophobia (fear of cats), and practiced ordering prescriptions, lab, and x-rays. I strolled around the hospital and greeted staffers.

I checked my email every 15 minutes for a reply from the College.

I walked back to the hotel for lunch and a nap. Still unlicensed, I returned to the facility.

By the end of clinic hours boredom set in. One of my colleagues called the College on my behalf.

Tuesday came as a replay. Clicking the REFRESH button every 15 minutes doesn’t count as exercise, and by noon I had started to ache from inactivity.

And I didn’t have cases to talk to my colleagues about. I missed being one of the cool kids who has stuff to talk about.

In the late afternoon my email lit up with notification of license reactivation, but I also had the chance to talk with the College about the possibility getting full licensure, making it return more flexible and shorter assignments possible.

I get my professional liability insurance through the Canadian Medical Protective Association (CMPA), based in Ottawa, 2 time zones to the East. So I called them at 6:30 Wednesday morning (8:30 their time), and by 6:35AM I had insurance.

At 8:00AM I strode into the clinic, grinning. In front of witnesses I signed my contract with Her Majesty, the Queen of England, and started into work.

I took care of my first patient of my return before the official start of clinic hours. I got permission to write about the problem, Eustachian tube dysfunction: the pressure in the ears which follows a cold or allergies and for which no effective medication exists. (Insurance rarely covers the only effective treatment, the EarPopper, a device that “pops” the ear, and costs over $300).

PTSD, chronic med refills, adult immunizations, and discussion of complicated endocrine investigations should not come to walk-in clinic. But they did.  At about 10:00AM I had a patient with a true urologic emergency, when I was running and hour late.

The day didn’t get less frantic after that, and I missed lunch.

I vastly preferred the action of the jam-packed day to the boredom that preceded it. And, at the end, I had cases to talk about, just like the cool kids.

 

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Physician, anthropologist, and bike mechanic

August 28, 2018

In on a cycle she rode

Out to the car park I strode

I helped out her knee

With a Sharpie, you see

And stayed true to my bike-fixer’s code

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in northwest Iowa.  Any identifiable patient information has been included with permission

People in my generation have lived with gravity long enough that we all have arthritis somewhere, mostly in the knees and back.

I attended to a particular patient (who gave me permission to write more than I have) with joint pains; she mentioned she rides a bicycle a lot.

I said, “Chances are if your knees hurt your bike seat is too low, and if your back hurts your bike seat is too high. Let’s go out and have a look.”  On the way past the front desk, I picked up a Sharpie.

A long time ago in an ER far away, a young man presented with knee pain. I looked at him, noting his footwear.

At the time, some cyclists used toe clips. Few used the cleats that lock the foot onto the pedal.  I asked the usual questions, and when he’d moved his cleats.  Then I disappeared for 30 seconds and came back with a 6-inch crescent wrench.  “I need to see you ride,” I said.

His machine came close to the finest that the early 1980s could offer. (If you must know, a Reynolds 531 frame with Campagnolo components.)

I had him ride once around the parking lot, and when he got off, I used my wrench to raise his seat 8 millimeters. He later wrote me a letter that his knee pain evaporated within hours.

Fast forward several decades. Bicycles advanced as bodies aged.  My 21st century patient’s mass-market vehicle had some wonderful components; I adjusted the seat height without a wrench.

After three successive approximations and three laps around the parking lot, marking calibration with the Sharpie, she rode with her leg almost fully extended at the bottom of the stroke, and declared her knee already improved.

Not relevant to the medical problem at hand, but part of my bike-mechanic ethos, I fixed her rear brake.

The human leg’s last few degrees of extension, the most efficient and the ones we use the most as we walk, involve an exquisite locking mechanism that lets us stand with no more energy expended than sitting.

She rode off into the late summer morning, I returned to the chilly, air-conditioned clinic, reveling in the synthesis of skills: physician, bike mechanic, and anthropologist.

The front desk staff stared at me.

“I fixed the problem,” I said, and returned the Sharpie.

 

 

A weekend call full of chest pain

July 9, 2018

This weekend I was hard pressed

And, as always I worried my best

The lilt in my song

Comes when I’m wrong

About the cause of pain in the chest.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission

I took ER and hospital call this weekend.

The chaos that suffused my time came as no surprise, but the consistent theme of the people seeking my services, chest pain, did.

The area involved can be anywhere between the diaphragm and the jaw. The complaint doesn’t have to include pain; so often the person says, “It’s not a pain, really, more of a discomfort.”  And, sometimes the patient doesn’t feel discomfort at all, but shortness of breath, or nothing more than fatigue.

Of course I worry about the heart. If the body’s main pump runs out of blood carrying vital oxygen, it can’t pause to rest, and parts of the heart muscle die.

But I also have to consider the possibility of pulmonary embolism (blood clot in the lungs), pericarditis (inflammatory fluid around the heart), aortic aneurysm (where the aorta, the main artery coming from the heart falls apart), cancer, broken ribs, pleurisy (an inflammatory roughness of the smooth shiny membrane that lines the chest), or esophageal spasm (a cramp in the in the swallow tube).

By the end of the weekend, the nurses had gotten used to my routine: an aspirin, chewed, and a nitroglycerin pill slipped under the tongue, both while obtaining an electrocardiogram and getting blood drawn for a series of tests. Sometimes I asked for chest x-ray, sometimes a CT of the chest to rule out pulmonary embolism.

Sometimes the studies revealed the problem, sometimes not. I saw a good cross-section of diagnoses including the profoundly serious and the mundane.  I sent patients out by ambulance and by car, and I kept a couple in the hospital for observation.

(Everyone in town knows the helicopter came and went; for reasons of confidentiality I will neither confirm nor deny it had anything to do with a patient I attended.)

I took care of patients from the age of 13 to the age of 88. I enjoyed talking to two consultants I knew from my private practice and Community Health days.

But the highlights of the weekend had to do with me thinking of serious pathology and being wrong.

 

Looking for things I don’t want to find

July 1, 2018

Pessimism is my inspiration

When I’m testing for inflammation

Sometimes we’re stuck

With a run of bad luck

I’m hoping for no information.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I make my living by thinking up worst case scenarios. As my knowledge and experience grows, I can dream up increasingly horrific things to rule out.

A lot of people, for example, just plain don’t feel good. I listen to the story, I take all the details seriously, I try to figure out the context, and then I go looking for diseases.  My favorites are the ones I can cure without specialist consultation, intrusive interventions, or expensive drugs.  I don’t like to find conditions that will last for the rest of the patient’s life, disrupting the plans of friends and family, misery that echoes down the generations.

Most disease, about 70%, comes to us directly from our choices: nicotine, alcohol, recreational drugs, overindulgence, and exercise avoidance.

But a sizeable portion of my work has to do with bad luck.

No matter what the source of the problem, my task is to make the patient better, and help the patient meet their goals.

But to get to that point I have to listen to the patient.

I listen a lot. I think pessimistically, and I run a lot of tests.

I use two particular assays, the C-reactive protein (CRP), and the erythrocyte sedimentation rate (ESR or sed rate) to make a major division in my lines of inquiry. Both seek to confirm or deny inflammation throughout the body, and two normals mean I can rule out a lot of illnesses. A high number in either parameter means I have to keep seeking till I find an answer, and, generally, an answer I don’t want to find.

Too many times this week I’ve looked at a lab sheet and used words unbecoming to a professional vocabulary.

At this point in my career, I shouldn’t take an abnormal lab test personally. I can either handle the patient’s treatment or I can find someone who knows more than me.

I look at the consequences of illness not just to the patient, but to the surrounding community. Every one of my patients exists in a context, and, just as the patient cannot be understood without understanding the context, the context cannot be understood without understanding the patient.

I shouldn’t take an abnormal lab test personally, but I do. Every patient is part of my context.

New Job, First Week

June 13, 2018

I laughed, and said with a snort

In the square of the town there’s a court

You could call the town small

There isn’t a mall

And friendly comes by the quart

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I saw a distressing number of serious pneumonia cases during my first week on the new job. Each patient presented differently, each brought in a life story from a family context.  And each challenged me in a different way.

We have exceptional pneumonia vaccines that don’t prevent pneumonia nearly as well as they prevent death from pneumonia.

In the last 40 years the disease has changed a good deal, and we’ve reduced the death rate, but not nearly enough.

The history and physical make the diagnosis more than anything. We listen for a crackling sound as the patient breathes in, but mostly we listen to the patient’s narrative.  Still we get blood counts, blood cultures, chest x-rays, and occasionally CAT scans.  A new blood test, pro-calcitonin, helps a lot but hasn’t made an appearance in any facility where I’ve worked.

I disappointed several patients by not finding ear wax.

I have acquired a minimalist approach to medication at this stage in my career, an approach that many of my patient appreciate. I especially enjoy stopping statins, a class of cholesterol-lowering drugs that can stop heart attacks and strokes, but will not prevent a first one after the age of 65.

The facility has a small staff and a small footprint. I counted 36 steps from my office to the ER, and 6 steps from ER to radiology.

I get a steep discount on meals, reasonable cooking served in reasonable portions.

Various licensing details have insulated me from the worst of the Electronic Medical Record (EMR) headaches, and I get to dictate my notes.

A small parking lot separates my accommodations from the ER; a landline assures good communications in the unlikely event of a sound night’s sleep.

I haven’t run into marijuana problems yet. Smokers constituted a surprisingly small proportion of the patients.  Not surprisingly, binge drinkers here, as everywhere, have difficulty with insight.

The facility has a gym, a CAT scanner, anesthesia, and a surgery program. I worked with two of the nurses here during my days in private practice, and I established a relationship with the radiologist during one of my other assignments.

Most of the referral traffic will go to Sioux City, where I still know many consultants.

And there’s an absolutely first class pizzeria about 20 minutes away.

 

High School Reunion 1: Siblings, sushi, and fractures

May 29, 2018

The cause might have what it takes

For the fractures that give rise to the aches

The stresses from running

Can be downright stunning

Bringing the ankles to breaks.

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. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, I am taking a break from Sioux City for my 50th High School reunion.  Any identifiable patient information has been included with permission.

I grew up in Denver. I went to a private school with uncompromising academic standards, and I returned here for the 50th reunion of my high school class, 1968.

My family arrived in 1956, when the city had fewer than 500,000 inhabitants. As I grew, the city grew.  I remember when the population passed a million.  I stopped growing, the city didn’t, and suburban sprawl long ago devoured wheat fields and cattle ranches.

I left Denver the first time in 1968, bound for Yale. My vow to never return lasted almost 6 weeks.  I returned in 1972 to do my pre-medical education at University of Colorado at Denver.

At that time I thought the traffic just barely tolerable, and I resented how much time I spent getting from one point to another.

I lived in my mother’s basement then, and regarded that house as my permanent address till 1979, when I finished med school, and cleared out my belongings on my way to residency.

I came in a day early because I still have family and friends in the Denver area. My parents passed away years ago.  Two of my sisters, one of my brothers and his wife, a brother-in-law, two nephews and a niece still live here.

I retain a map sense of the city’s general layout. The major arteries have changed; Interstate 25, which we used to call the Valley Highway, runs 8 lanes through the city.  Santa Fe Drive, formerly the Santa Fe Trail, has entry and exit ramps.

I marveled at how much the air quality improved in the last 50 years, despite obscene traffic, and equally at courtesy of the drivers.

In the late afternoon my sister, her husband and I went to meet my brother, his wife, another sister with her boyfriend and two children for sushi. My niece fell and injured her wrist, necessitating a trip to Urgent Care and thus a change of restaurant.

Our family likes to gather, we go out of our way to do so, and this time my arrival served as the excuse.

My brother had just finished taking the Medical College Aptitude Test (MCAT), and he asked me what it was like when I took it in 1974. I could but remember one question, and that regarded Saladin and his place in the history of the Crusades.  I hadn’t known about him when I took the exam, but I looked him up afterwards.

The MCAT’s General Knowledge section, which contained that item, has since dropped out of the exam due to massive cultural bias. Medical schools still use the MCAT score and the premed GPA as inflexible cutoffs.

My sister and her children joined us while we munched edamame. My niece broke both bones of her right forearm just about the wrist; she came in with a sugar tong splint and a sling.  Towards the end of the meal her facial expression told us all that her ibuprofen had worn off.

I showed her how to put her wrist over her head. Within a minute a smile reigned and she went back to giggling.

I told her to use gravity as an ally whenever possible, as gravity inevitably pulls downhill the swelling that amplifies pain.

Soon the adults told broken bone stories.

At age 17 x-rays showed stress fractures of my lateral malleoli: breaks in my outside ankle bones sustained from compulsive running.

Normal teenagers don’t run so far or so hard that their bones break, and, perhaps, normal people don’t come back for their 50th reunions.

 

 

Weekend call: propranolol, Mounties, x-rays, Dave Brubeck, and geographic confusion

April 16, 2018

Geography knowledge is rare

And even those doctors who care

Have recommendations

That get emendations

With exclamations of “WHERE??!!”

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. After a month of part-time in northern Iowa, a new granddaughter, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

Another weekend on call has passed. The heaviest day was Saturday; I attended 13 patients.  For the most part people came in a steady stream, yet I got breaks for lunch and supper.  With no regrets, I took every opportunity to nap.

I saw 4 Workman’s Compensation cases and 3 others from a motor vehicle crash. I don’t know why, but  I stand to benefit from laws governing reimbursement these two classes of injuries.  They represent the only two Canadian system areas lacking crystal-clear transparency.

My broad background helps me connect with a wide variety of patients. I relied on my short musical career to help one patient.  In the ‘60’s the Dave Brubeck Quartet’s artistry enchanted me into relentless listening of the ground-breaking album, Time Out.  I advised the patient to check two cuts on YouTube, Take Five and Unsquare Dance, examples of drum solos in difficult, unconventional rhythms (5/4 and 7/4) taken to artistic extremes.

I used my 7 years’ experience attending Adult Children of Alcoholics meetings to help another person. I pointed out that, just as perfect people rarely come to see me, perfect people rarely choose to become doctors.

I dealt with patients with neurologic, respiratory, infectious, psychiatric, blood, eye, gut, skin, and bone problems. I ordered and interpreted 3 electrocardiograms (all normal) and two x-rays (both abnormal). Four people had viral illnesses, expected to resolve with no treatment.   I ran 2 urine drug screens, results from one but not the other had surprises.

I sent one patient by ambulance to Prince George.

I called the Mounties once.

I ordered two CT scans for the upcoming week, fairly confident that one will come back normal and concerned that one might not.

I sought consultation from a Vancouver specialist who gave me a series of recommendations. After I hung up I called back.  She hadn’t realized the geography involved.  Just as well.  The patient (rationally, I felt) refused those measures.

I prescribed propranolol twice. With the blood pressure indication eclipsed by better drugs in the same class, it still has a lot of off-label uses: migraines, ADHD, stage fright, performance anxiety, premature ejaculation, rapid heart rate, tremor, and buck fever.  It stands as the first-line treatment for over-active thyroid.

I drove rather than walked the kilometer to the hospital. Temperatures have stayed close to freezing, with daytime thaws since I arrived, and frost coated the car windows after sunset.  This car rental didn’t include a scraper so I used a movie rewards card.

Morning crisis, skin biopsy

April 10, 2018

It’s hard to make sense when you’re stressed

And sickness makes you depressed

I won’t interrupt

Nor be abrupt

If you’re in crisis, I will do my best.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, 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. After a month of part-time in northern Iowa, a new granddaughter, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

Depressed people get sick, sick people get distressed. Just as a bridge fails under maximum load, people come to see me when they come to a breaking point.  To do the best for a patient in crisis, I have to listen, and to listen, I cannot interrupt.  People in emotional turmoil frequently don’t know what they want to say, and if they do, they have trouble articulating.  Often, the first patient of the day fits this description, and the time required invariably spills into the next patient’s time slot.

While I can take pride in my work by handling the situation well, I have to apologize to those whom I kept waiting.

Later that morning, a patient expressed concern about a mole (and gave me permission to write about it) that had radically changed in the last two weeks.

When we evaluate moles, we talk about the ABCDE (asymmetry, border, color, diameter, and evolution) criteria to separate the worrisome from the mundane. Even a perfectly symmetric mole with a regular border, homogenous color, and a diameter less than 8 mm deserves biopsy if it changes.

The mole in question had rapidly expanded until I could not cover it with my thumb, spots of black and white marred the overall pink color, in places the edge wandered. All in all, the worst mole I’ve seen so far this century: almost certainly malignant melanoma.  I strongly recommended biopsy, with the intention of doing the procedure immediately.

Last century, at a different clinic, I spotted a worse mole the size of my hand on the back of someone sent to me (rather than his regular doctor) for a work physical, and recommended he get it taken care of definitively as soon as possible. He returned 18 months later for a biopsy, and ever since, if at all possible, I do the biopsy the same day.

Moving to ER, scrubbing, anesthetizing, removing a 5 mm circle from the mole, and putting in a stitch took less time than finding the equipment.

I finished the morning more or less on time but with no documentation done.

And the documentation came harder; in succession I had seen two patients of the same ethnicity, age, and gender, with similar problems but very different diagnoses. I relied on notes I jotted during the visits.

April 7, 2018

Of the patients there’s never a lack

I can tell you it’s good to be back

I think that it’s neat

When the patients repeat

And I can see that they’re on the right track.

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. After a month of part-time in northern Iowa, a new granddaughter, and a friend’s funeral, I have returned to British Columbia.  Any identifiable patient information has been included with permission.

Today I cared for 12 patients, 1/3 of whom I had cared for either last summer or in December. Respiratory problems dominated the clinical landscape, but I also saw 3 who came in to find out test results and five who needed prescription refills.

I recognized the first patient and without prompting opened the visit in French. He gave me a heartfelt grin.

I recognized one patient as a New Zealander by his accent. At the end of the visit I got into geographic specifics, and in short order we started talking about Warkworth (pronounced Walkwith), Leigh (pronounced Lee), Matakana, Omaha Beach, the Kauri Museum, Pakiri Beach, and Whangarei (pronounced Fahnga Ray).

Three patients discussed travel to Mexico, either completed or anticipated.

In December I posted about a patient whom I gave the opposite of my usual dietary advice; she returned to see me today. The plan worked, and the problems related to excessive weight loss disappeared.  We discussed favorable labs, and she requested I write about her in more detail.

A quarter of the patients use marijuana regularly. The only smoker wanted to quit.  Nobody admitted to excessive alcohol.

I did yoyo tricks for my one pediatric patient.

The return to work came as a relief after two months without employment. Including those seeking casual medical advice, I averaged less than 3 patients a week since February 1.  Today I fell into the rhythm of my usual questions: tell me about it, tell me more, what else?

News of my Immigration problems circulated here even before I published my last blog post. Patients, staff, doctors, and bystanders commiserated with me.  I pointed out there are few better places to be stuck than Vancouver.  We all agreed if you have to get turned away at a border, none can beat the US-Canada border.

A lot of people, in the clinic, the hotel, and the mall, asked after my wife, Bethany. She made a lot of friends during our last two stays. I got the feeling people missed her as much as they did me.

It was good to be back at work, in a system centered on patients and not cash flow. And it was good to be with a bunch of my colleagues, talking about cases and learning from each other.

At the end of the day, pleasantly tired from the action, but far from exhausted, I stepped out into bright sunshine and temperatures just below freezing. I had finished all my documentation.  I didn’t have to think about anything else but the weekend.

 

 

What not to do for bite wounds

March 24, 2018

I’m at leisure, but I’m not at rest

And I always still try my best

By day or by night

Don’t sew up a bite

Just leave it cleaned up and dressed.

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. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

 

Even without a regular office or practice site, people ask for my expertise. I can’t discuss the people without their permission, but I can discuss, in general, certain medical conditions.

Dogs, cats, and humans inflict the vast majority of bites in 21st Century USA, not surprising as these comprise the species with the most human contact.  Cat bites almost always cause infection, and human bites, though less dangerous than cat bites, carry large amounts of really nasty bacteria.  Dog bites carry less than half the risk of infection of the other two, but still deserve a good course of antibiotics.  I prefer amoxicillin/clavulinate for bite wounds.  I always have to consider if the bite was provoked, and, in the case of pets, the vaccination status.  Running tap water and soap cleanses wounds as well if not better than sterile water or peroxide, and drug stores sell the best dressing supplies.

(In Africa, the most common fatal bites come from hippopotami).

I don’t suture gaping skin wounds from bites unless on the face or genitals; I advise the patient they’ll have a scar. Sewing the wound predisposes to having a wound infection, and having that infection turn ugly.

When I treat overuse athletic injuries (including workman’s compensation cases) I rarely recommend complete cessation of the activity, partly because athletes won’t listen. I advise decreasing the stress (whether by duration or intensity) by 1/3 for 3 weeks, then increasing by 10% or less per week.  Perhaps those under 18 can bounce back faster, but mostly I deal with the others, the ones who comprise the “aging athletes.”

Then comes the eternal RICE protocol: Rest, Ice, Compression (such as an Ace bandage), and elevation. For cooling, I prefer a cold (not frozen) can (not bottle) of regular (not diet) soda.

The medical profession has used those principles for 40 years, they still work and have few side effects.

Several decades ago I completely some surveys (really, very thinly disguised marketing ploys) and in return received, as compensation vouchers for medical equipment. I now own seven stethoscopes, four head lamps, and two splinter removal kits.  Those kits have extremely sharp tweezers, which make extracting slivers of wood from the skin much quicker than using a hypodermic needle.  Which I can use, in a pinch.