Archive for the ‘Medical Care’ Category

A moral dwarf amongst real veterans

March 14, 2019

Technically, you can call me a vet

Though I never faced much of a threat

And now the VA,

Making up for bad pay,

Is paying off Uncle Sam’s debt. 

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

Bethany and I drove up to the Sioux Falls VA hospital for my annual rheumatology appointment.

I have ankylosing spondylitis, a close cousin of rheumatoid arthritis which primarily affecting the spine.  It hurt me since before I turned 18 until my first injection of Enbrel in 2000.  It kept me out of Viet Nam, but not out of the Public Health Service.

So that I now qualify for Veterans’ Benefits, including health care.  The VA pays for an injectable medication which would retail at over $60,000 per year.  When I need a refill, I make a call and it appears on my doorstep in a Styrofoam insulated box in 2 or 3 days.

By comparison to the price, one 2-hour drive and 4 lab appointments yearly rates as a Best Buy.

Because I hurt for so many decades, by the time the pain stopped my body had gotten really good at generating and recognizing endorphins.  All in all, I feel better than I did when I was 18.

And when I sit in public places, I never stop my physician observations, even when I’m a patient.

I watched and listened to the Real Veterans in the waiting rooms today, and I made diagnoses.  The swollen knuckles of rheumatoid arthritis.  The blotchy facial redness and bags under the eyes of alcoholism.  The bug eyes of hyperthyroidism.  The slowness, shuffle and tremor of Parkinson’s.  Way too many “thousand-yard stares” of PTSD.  The scalp scars, cane, and abnormal gait of a traumatic brain injury.  Too many missing limbs to count.  Behind me, the conversation’s speed and volume (loud enough to hear, too fast to understand) of bipolar mania.  The hopeless faces of depression.   And attentive spouses steering veterans in wheelchairs.

While the lab tech (who gave me permission to write this) drew my blood, I noticed swelling in the front lower part of her neck.  I told her to get her thyroid checked, specifying thyroid stimulating hormone (TSH), and anti-thyroid peroxidase (TPO); and an ultrasound if those tests come up normal.

It doesn’t take much historical knowledge to be able to recognize the conflict that modified the hero.  Although, with two fronts ongoing for the last 25 years, I can’t tell the Iraq vets from their Afghanistan contemporaries.  Some served in both theatres.  Some Korean vets served in Viet Nam.

I don’t feel myself a veteran in the presence of the real ones, I feel a moral dwarf.  I never faced a greater danger than a drunk’s slow punch in the ER.  I put up with bad pay and bad management for 5 years.  I lost income, my fellow beneficiaries lost things that cannot be replaced.

Still, the VA treats me the same as they treat the Real Veterans.  Part of the culture of VA employees involves a lot of caring and warmth that people bring from their hearts but the Federal Government does not pay them for.

For my time in the Public Health Service I got 5 years of cross-cultural experiences that could never be purchased.  And now I get benefits equal in value to a good full-time job.

 

 

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March 10, 2019

I had me a weekend on call

With patients good-looking and tall

As the assignment will end

A free day I’ll spend

And perhaps I’ll return in the fall

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. After 3 weeks’ vacation in Texas and Denver, I have returned to northern British Columbia.

I had call for this locum assignment’s last weekend. Things started abruptly with three complicated patients already in Emergency.

Over the course of the weekend I hospitalized one patient overnight.

Winter sports generate their fair share of injuries. Despite good protective equipment I took care of hockey players who encountered a basic truth of the universe: two objects cannot occupy the same space at the same time.

I have not seen nor heard of a curling-related injury. That sport has limited following in the US, perhaps because of its lack of violence.

Newton’s 3 laws (a body in motion remains in motion unless acted on by an external force, a body at rest remains at rest unless acted on by an external force, and every action has an equal and opposite reaction) applies to skiers and snowboarders, no matter how good-looking they are.

Canada legalized marijuana less than a year ago. The legal stuff carries high potency, and comes at an affordable price.  I cannot for the life of me figure out why anyone would run the risk of illegal adulterated weed in the face of accessibility of a relatively pure product.  But some people do.

In other places, at other times, I’ve taken care of people who consumed so much alcohol that they lost consciousness during winter snow falls. Brought to the ER, the ambulance crews could estimate the length of time they had been exposed to the cold by the depth of the snow that had accumulated.  Not one of them developed frostbite.

Which does not mean I don’t see an occasional case. The most memorable one came one summer in New Mexico, when the patient, bitten by a rattle snake and ignoring instructions to keep a layer of cloth between skin and ice pack, froze the top layer of skin.

When the sun came up Monday morning I could account for a decent 6 hours of sleep.

The weekend call doctor here gets Monday off. After a leisurely breakfast, I came in about 9:00AM and started working on clearing up administrative odds and ends.

The office manager found me after lunch, hard at work rewriting a referral letter that I’d sent to the wrong specialist, not realizing two had the same distinctive, 4-syllable name.

The government covers rural physicians for 43 days of yearly locum tenens, running from April 1 to March 31. She explained that my Sunday call exhausted that particular account.  Tuesday, this assignment’s last day, could not be paid for.

I grinned.

A day off.

Part of the adventure.

 

 

 

Teaching 3 things I didn’t learn in med school

February 26, 2019

The student might have thought I was mad

When I lit up an alcohol pad

And then used that fire

To heat up a wire

But then I made happy the sad.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. After 3 weeks’ vacation in Texas and Denver, I have returned to northern British Columbia.

Some of the docs here have decided to split weekend call so as to avoid working 72 continuous hours, a step I regard as so healthy that I volunteered for Saturday call last weekend. I had the chance to teach a medical student, Dyon, who intends to do a Family Practice residency.

All patients mentioned gave permission to write about their cases.

The first patient came in with a subungual hematoma, or blood clot under the finger or toe nail. A very painful problem, but one easy to cure by putting a hole into the nail.

The nurses couldn’t find the usual tool, an electrocautery, which looks like a disposable electric soldering iron.

I taped an unfolded paper clip to a tongue depressor with 3cm of wired extending past the end. In the absence of a Bunsen burner, I turned an alcohol pad into an alcohol lamp by tearing a corner from the foil packet and lighting it with the patient’s cigarette lighter.  The student, in his capacity as fireman, held the flame close at hand.  I kept the paper clip tip in the hottest part of the flame till it glowed, and applied it to the nail.  It sizzled nicely but cooled too quickly to go all the way through.  The first “alcohol lamp” burnt out before resolving the problem.  Then the patient volunteered to keep his lighter burning.  On the 3rd try, the glowing metal melted the nail, and close to half a teaspoon of dark red blood spurted free.  The patient, like most in his situation, had such relief that he started to chuckle, probably from endorphin rebound.

In short order we faced an 11-month-old, and another chance to teach. When babies, about 10 months old, distinguish family from non-family, they fear strangers.  While humans can see from birth, it takes till age 9 to fully organize the information coming from our eyes.  Thus, if you don’t make eye contact with a 10-month-old patient, you can examine the ears without force or trauma; they think if they can’t see you, then you can’t see them.  The trick worked on the 11-month-old.

About an hour after, an adolescent arrived with a toothache. Standard treatment consists of pills for pain and infection; in addition I showed the student, the patient, and the parent how to find the acupuncture point that the Chinese call Ho-Ku and that Western anatomists call the branching point of the superficial radial nerve.

For all three patients I got to show off knowledge acquired outside of medical school.

Saxophone and life lessons

February 3, 2019

In Memoriam

Diane G.

March 28, 1960- January 24, 2019

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. Just back from my 4th Canadian assignment, I’m taking some time off in the States

After a miraculous, 15 year fight with cancer, Diane, my friend and saxophone teacher, died last week. I was with her when she passed, not as her physician but as her friend.  Bethany was there as a friend as well, and to support me.

She died surrounded by the love of her friends and her family.

Diane had to see other physicians while I went locum tenens, but I never found another music teacher. Thursdays when in town meant life lessons along with music.  She would not accept money, so I brought chicken soup.

At her urging, and with her permission, I wrote about her in 2011. I have included the post word-for-word below.

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog.

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant.

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her.

“Well,” I said, “Just lay back on the exam table while I check your tummy.”

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart.

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post https://walkaboutdoc.wordpress.com/2010/05/23/can-a-soprano-beat-a-naked-lady/)

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.

 

 

 

I’m the doctor. You need the dentist.

January 15, 2019

It doesn’t take much of a sleuth

When it comes to a pain in the tooth

In the head, but not mental

Those problems are dental

They start in the mouths of the youth

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

 

Canada’s recognition of care as a right means that cost comes out of everyone’s taxes, and, in that sense, everyone has health insurance.

(Actually, they don’t. The Mennonites, for example, do not have to pay those taxes.  And I ran into a young man with such massive self-defeating behaviors that he procrastinated getting his insurance card for 4 years.)

The mainstream plan does not cover dental work.

The bigger employers offer dental insurance, but, like the US dental insurance, it has a high deductible and large copay. Thus people tend to ignore their teeth.

I see between two and four patients a day with dental problems; a higher percentage when I’m on call. About a quarter of those who come in with toothaches have never visited our facility before.

If people didn’t hurt a lot, if they could get in to a dentist close by, they wouldn’t come in to ER with dental pain. When they open their mouths, I see decades of procrastination and neglect.  Broken teeth, teeth rotted to the gum line, teeth worn out from the clinching that methamphetamine brings.

I can’t actually fix the problem. I can give antibiotics and pain relief.  Amoxicillin remains the standard in dental infection.   For analgesia, I have the nurse administer ketorolac (Brand name, Toradol) 30 mg as an injection, and I give the same medication as a pill for 5 days.

If time permits I show the patient ho-ku acupressure, squeezing a point in the muscle between the thumb and forefinger, which relieves head and neck pain.

But I have to urge them to get into the dentist as soon as possible. For those who can’t afford to pay, I give them information on the free dental clinic held twice monthly in Prince George.  Staffed by volunteers, they rarely have time to do anything besides pull the offending tooth.

I suppose I could learn to do dental extractions. If I did, in short order I’d be doing almost nothing else.

Some of the patients don’t have a problem till they’re about to head into the wilderness for work for a few days; I generally give them a longer prescription of Amoxicillin, but I don’t give out pain pills that would make them dangerous around machinery, or driving to Prince George.

Confronting a smoker with a heart attack

January 13, 2019

 

When it comes to attacks of the heart

Please listen, you docs who are smart

Whenever the bloke

Steps out for a smoke

Don’t yell, and keep your words smart.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

Though the patient gave me permission to write about him, I won’t say when this incident happened.

He came in with chest pain. As per protocol, I did the electrocardiogram which strongly resembled previous tracings.  But I also asked for and obtained a blood test for troponin, which rises only when heart muscle has sustained damage.  It came back normal.

But we have learned that sometimes the damage doesn’t show up on the initial blood work, so I ordered the same tests 4 hours later.

I read the second ECG with alarm: a sag in the line connecting the wave representing the heart’s contraction, with the deflection of the heart’s electrical preparation for the next beat. I sat down with the patient and discussed the situation.  In the middle of a heart attack, I had to make arrangements for more specialized care.  He would require a cardiologist and a catheterization, perhaps stents or a cardiac bypass graft.

I started the complicated business of sending the patient to a higher level of care while the snow fell hard enough to make the task impossible. I repeated the same story on the phone, each time emphasizing that the patient remained pain-free and with normal blood pressure and pulse.

The snow eased my emotional frustration. No medevac helicopters fly in this health district.  I only ask for fixed-wing transfer when justified by the distance to the facility, and the weather throughout the province assured that the small planes involved in medical transfer could neither take off nor land.  Still, the decision-making came at day’s end.  Vancouver’s cardiologists had no beds, we would have to keep the patient.

As I finished the hospital admit process, the nurse said, “You know, don’t you, that he stepped outside for a smoke.”

No, I hadn’t known. I confess I lost my temper.  I slammed my pen on the desk and stormed out to the front entrance.

I confronted the patient.

Those who have known me the longest will confirm that when I get angry I get articulate, but I rarely raise my voice. I don’t have to.

What I said boiled down to, “You have a beautiful young wife and a son. There are a lot of people who love you, and we’re worried about you.”  But I said it, angrily, about 6 times.

I care about my patients, but I haven’t expressed that kind of fury for years. Maybe I’d worked too many hours with too much noise.  I finished more fatigued, and I felt worse for hours.

The next day the patient thanked me, as did his family. He felt better, the best he’d felt in a year.

Outside, the snow fell thick for the next five days, when, finally, we got word we could transfer.

Eye color change, addicts with insight

December 11, 2018

A change in the color of eyes?

It comes as quite a surprise

It can happen, it’s rare

It’s more common in hair

Don’t count on it for a disguise

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and northern British Columbia. I have returned to Canada now for the 4th time.  Any identifiable patient information has been included with permission.

I found myself on call this morning, glad that it came as a surprise so I didn’t have the anticipatory anxiety the night before.

I recognized a person who came in accompanying an ER patient, but I had problems with the appearance.

I had seen the patient weeks before, with a very puzzling physical finding, and tonight I got permission to blog about it.

Presenting complaint: eye color change. I hadn’t heard of such a thing, and I hid my skepticism.  But I did ask for the driver’s license, which confirmed eye color as hazel.  Yet the patient, without a doubt had blue-grey eyes.  I posted an inquiry on a doctors-only clinical social media website.  About half the responses derided the very idea.  But one ophthalmologist offered an erudite discussion and attached a link.

Indeed, eye color can change.

So I thought it over. Eye color depends on little packets of pigment called melanosomes.  I already knew that some unfortunate people can lose color from patches of their skin in a process called vitiligo (two prominent examples include Michael Jackson and the Pied Piper of Hamlin).  And if a person loses a patch of hair to alopecia areata but the hair grows back, it will usually grow back white, due to a loss of melanosomes.

So, if that can happen in the skin, when not the eye?

The patient’s eye color had since darkened, now having bits of brown and green, enough to throw off the appearance.

I said that discussing such a rare finding would come close to identifying a patient.

The person happily gave permission for me to write about the incident in my blog, and talked about running into others who similarly had seen their irises go from dark to light.

Eye color change happens little more rarely than addicts acquiring insight, yet for the 7th time in a week an addict came to clinic knowing change was needed, having started the change, and requesting counseling.

Note: this post made it into the draft queue and marinated there for more than a week.  Since then I’ve had 5 more addicts come in with insight, requesting counseling.  Some have already started going to meetings.

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.

 

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.