Archive for the ‘Medical Care’ Category

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.

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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.

After two unemployed months, back at work

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.

When the surgeon advises no surgery

March 1, 2018

From Galveston we drove in the rain

To discuss a tumor of brain.

To our great relief

And we love the belief

That surgery would be in vain.  

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. I’m taking some time off after a month of part-time (48 hours per week) work in northern Iowa. Right now we’re in Texas visiting our married daughter, her husband and their new baby. Any identifiable patient information has been included with permission.

MD Andersen could lay claim to the title of America’s Premier Cancer Hospital. The exam room at the Brain and Spine Center on the 7th floor of Building 3 held more than a century of education.

I have had 27 years of formal education; my wife has 20 years of schooling including a bachelor’s, a master’s, a year for her Certified Medical Assistant, and another for advanced educator training; our oldest daughter, a Family Physician in her own right, has 23 years. The two neurosurgeons have at least 27 years each.  Including Anya, our 12 day old granddaughter, the average number of years in school came to 21.

But the two neurosurgeons spoke directly to the patient, my wife Bethany. A routine MRI in the summer of 2016 found a meningioma, a non-malignant thumb-sized brain tumor growing out of the floor of the skull just behind the left eye.  She had radiation therapy that August and has remained symptom free since.

But follow-up MRI in Sioux City showed mistiness suggesting possible tumor growth, and we came to Houston for another opinion about proposed treatment.

Actually, we came to Texas to visit the new grandchild. Jesse arranged for a consultation and drove us through the pouring South Texas rain, up from Galveston.

I listened in while the neurosurgeons explained the findings on the scans. The tumor itself shows a clear-cut outline or capsule; the haziness around it does not connect with the meningioma proper, and probably represents radiation necrosis, that is, death of brain tissue from the radiotherapy.

To our great relief, they strongly recommended against surgery, and prescribed a quartet of drugs: steroids to take down inflammation, Vitamin E as an antioxidant, pentoxifylline to make the blood less viscous, and pantaprazole to prevent an ulcer from the steroids.

We all felt relief flood the room. And I’m sure little Anya, who knows nothing cognitively but stays locked to her mother’s emotions, felt it too.

I had my work calendar cleared out because of worst case scenarios. That night, while thunder rolled over the Gulf of Mexico, Bethany I and snuggled in the darkness and talked about Where To Go Next.

 

Sense of humor restored

January 25, 2018

 

Thinks of all the calls that I dial

And the round trips I make by the mile

And the hours on hold

Can leave my humor just cold

But it got restored with the sight of a smile.

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.

I go out of my way to keep a sense of humor. But I’m only human.

I had 8 patients on the morning clinic schedule. I cured the first patient of the morning and sent him on his way.  I returned to a clipboard with 4 sheets of redundancy inherent in a government-based workman’s compensation case.

About 11:00AM nurses told me of an arriving ambulance. By that time I had 5 undictated charts.

The hundred paces to the ER disappeared rapidly under my shoes. I took the history, ordered the CT scan and some blood work, and quick-stepped back to the clinic.  I knew I faced a serious, complicated case which would require a transfer and demanded prompt action.  I finished the last three morning patients and retreated to the break room to listen to the drug rep pitch very expensive asthma drugs and bolt Chinese food.

At 12:45PM I returned to ER just as the patient got back from CT. I finished the history and physical, and awaited the radiologist’s call.

I started with a call to the transfer operator, and the basic clinical picture. Then to the hospitalist, who accepted the transfer.  I started typing up the history and physical and was 75% finished when the hospitalist called back, clarifying some historical details.  Is the patient OK for MRI?

Trips back and forth from my work area to the ER. Calls to a specialist in Minneapolis.  Holding for 10 minutes at a time, while patients waited in the clinic and the piles of unfinished documentation fermented.

No, the specialist said, not a candidate for MRI.

On hold for another 10 minutes with the hospitalist. Do not send patient without speaking with neurosurgeon.

Twenty minutes later the neurosurgeon, dithered for 5 minutes and refused the transfer, and recommended Mayo clinic.

I considered how badly things could go during the hours necessary to get to Rochester.

The nurses recommended a competing Sioux Falls hospital. I announced that my sense of humor was weakening.

Another 5 minutes on hold. The hospitalist accepted the transfer graciously.

I gave the history and physical last-minute revisions to reflect the past two hours of clinical and clerical actions.

With the paperwork all packaged, I went back to the clinic. After 3 hours of the drama, irony, and frustration inherent in trying to be two places at once; after all the tension built into a system of inefficiencies dedicated not to patient care but to the cash flow generated thereby; after literal miles of fast walking hospital hallways, I stepped into the exam room.

The patient whom I started on Parkinson’s medication last week beamed at me when I walked in. The very small doses of a very old drug had done their job; the patient (who gave permission to write more than I have) bloomed.  Now the smile went all the way to the eyes, the speech had music, and the expressions danced on the face.

In less time than it took to shake hands, my sense of humor returned.

Yes, emergency work brings me challenging cases, but I do not want to give up the satisfaction and gratification that comes with patient follow-up.

Spanish, spinal manipulation, and zoonoses

January 24, 2018

The patients come in, I’m a doc,

And I ask, Are you working with stock?

Do the animals thrive?

Are they even alive?

How big is your herd or your flock?

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.

(Post generated week of 1/15 and held till now.)

I faced subzero temps and 40 MPH winds on the drive into work today. Still I came in to find my morning schedule full.

Which conflicted with a complicated ER patient, requiring hospitalization, and, eventually, a very complex transfer. So today I started counting the steps between my clinic work area and the Emergency Department.

The steps added up to 100 each way, but I lost track of the number of times I made the round trip.

Midway through the morning, I noted a holster with a pair of pliers on a patient’s belt. Obviously a quality piece of leather, and just as obviously worn daily for many years, I made the observation that even an American-made pair of pliers has a finite life expectancy if used often, and asked how many pairs of pliers he’d been through.  He chuckled.  He’d been through three pairs so far, and the holster had been custom-made for him.  He gave me permission to recount our conversation.

A lot of farmers and other agricultural workers come to see me. The rules on antibiotic stewardship do not apply to people who work with livestock.  I have concerns not only with zoonoses (diseases acquired from animals) but with the hazard to the animals if the patient transmits microbes.   I generally don’t give out antibiotics for respiratory infections under 5 days duration, but I make exceptions, for example, for those who have just removed thousands of dead or dying pigs from a hog confinement. So along with asking if a person uses tobacco, or if a woman might be pregnant, I ask, “Do you work with livestock?”

Today was a good day for speaking Spanish, relieving suffering among patients from teenagers to septuagenarians just with my fluency. I fielded the usual question:  Where did you learn Spanish (high school, but I’ve been practicing for 50 years), and also, Are you Cuban?  (no).

At one point a non-physician clinician needed an interpreter while I worked my way through clinic, and the nursing staff activated a video service. When I returned 40 minutes later I immediately recognized an accent from Spain, but I did not get a chance to chat up the interpreter.

By the end of the morning, I had cured three patients before they left (ear wax removal for one, and spinal manipulation for two). But the ER patient would stay another 3 hours until transfer could be arranged.

I left in the dark, in subzero temperatures, ferocious winds, and a light snow.

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.