Metric ambivalence and slices of Canadian life

June 5, 2017

Out here where it’s too north for wheat,

People use both meters and feet

The confusion rebounds

Between kilos and pounds

But can Celsius make Fahrenheit delete?

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

Canada officially uses the metric system, but, unlike New Zealand, they have a lot of ambivalence. Today, at the grocery store (the town has a very good one) we bought things by the ounce, pound, gram, kilo, fluid ounce, quart, milliliter, cc and liter. Carpenters use 2×4’s, plywood comes in 6’x8’sheets.  Most everyone uses Celsius to talk about the weather (even I know my favorite metric temp is 18), but when I ask about fever, half the people answer in Fahrenheit.  One patient described an involuntary loss in pounds, but all the clinic scales weigh in kilograms.  Almost no one knows their height in meters, but they do know their height in feet and inches.   People talk about their cars’ mileage in kilometers per liter, but don’t recognize the linguistic dissonance until I point it out.

At one point this last week I sat with the patient while waiting for a staffer to bring some documentation. The patient told me about an American TV game show, where contestants were asked how safe they feel in their homes, and some didn’t feel safe at all.  The patient asked, “Are things really that bad in the US?  Are people really that fearful?”  I said that it all depends on the place.  I had just finished 14 weeks in a small town in Iowa where people leave their houses and cars unlocked despite the presence of a prison in the town.  On the other hand the big cities have their high crime zones.  “How safe do you feel,” I asked, “In Vancouver?”

Gasoline runs a little over a dollar a liter here, which comes to $3.17 per gallon at current exchange rate. Quite inexpensive compared to New Zealand, and very reasonable considering the distance it must be trucked to get here.  The country has no posted speed limit higher than 100 kilometers per hour (about 62.3 MPH).  Because I take speed limits seriously, as I have no wish to get another international speeding ticket (I had one in New Zealand), I get great mileage in the small Korean car I rented.  But I get passed a lot.

Cigarettes here run $12/pack, a little less than twice the price in Iowa. The national rate of smoking in the US dropped to 16% two years ago, in Canada it’s now 15%.  Still, more than half of last week’s patients smoke.

A surprisingly large majority consumes no alcohol, and almost no one uses marijuana. At least, that’s what they tell me.  And I believe them.

 

Thursday last week I started to work

June 4, 2017

I took care of the patients I got

I gave a couple a shot

But for one of the rest

I’ll need quite the test.

The work just hit the spot.

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

I started the day early, and lingered over breakfast while I watched a YouTube video about the underlying geology of northern British Columbia. The clash of tectonic plates has resulted in a coastal mountain range separated from the west edge of the Canadian Rockies by a central valley, everywhere scarred by the violence of glaciers.  All in all, I’m experiencing lovely scenery in an orderly, safe community where the children can walk unaccompanied to school.

Now 4 days into my Canadian adventure, I came to work this morning prepared for orientation in MOIS, the Electronic Medical Record (EMR) system (and my 15th in 30 months), but, alas, still lacking password sign on.

I took care of the latest, and hopefully last, couple of glitches in my bona fides. I did some email.  At the very last part of the morning, I started EMR training, which I followed by playing with the test patient named Mickey Mouse.  I knew immediately his birthdate was off, but finding citalopram (an antidepressant) on his med list came as no surprise.

When I came back from lunch, I had my first patient on my schedule.

I immediately fell back into my 3 question rhythm: Tell me about your problem.  Tell me more.  What else?

Though just starting on the learning curve for the EMR, and though I needed EMR coaching 5 times for 6 patients, this system seems easier to learn than most. Or maybe I have learned how to learn.

Two patients needed injections, three patients’ problems centered on their right leg. The last patient of the day turned out to be more complicated than anyone could have imagined, and will need follow-up and work-up.

To my surprise, the doctors here do their own injections, a job in the States uniformly delegated to RNs, LPNs, and, sometimes, Certified Medical Assistants. I have had to learn injection techniques on myself, as I take vitamin B12 shots into the muscle monthly, and Enbrel injections into the fat just under the skin every 5 days.

I took care of a total of 6 patients in the afternoon. Still clumsy with the EMR, I didn’t finish until 5:00PM, an hour after the clinic closed, but still a good deal earlier than what I’ve been doing for most of the last 40 years.

I thoroughly enjoyed myself.

 

 

Short commute, insurance progress, and circumcision equipment

June 1, 2017

After a couple of years in the prep

I’m closer now by a step

I have the assurance

Of malpractice insurance

And the idea of work gives me pep.

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

Living walking distance from work ranks as a quality of life measure in my book. Here it takes me 20 minutes, a way to build exercise into my day.  I don’t worry about the bears enough to carry pepper spray.

Today I confirmed my professional liability insurance. The Canadian Medical Protective Association normally takes 2 weeks to process a new account, but when I called the polite, friendly person I spoke with exercised great flexibility and understanding and got my coverage started, as of the first of June.

I hope that I can start seeing patients the day the coverage begins.

I got a chance to meet one of the other doctors who, despite taking time off, dropped by the office. With as much warmth and humor as permeates the facility, I can see why he would.

I have found the people here friendly and welcoming, appreciative that I’d spend 3 months here, and eager for me to enjoy myself.

We had another meeting over submarine sandwiches and soup. At the end, I volunteered to find out what we have to do to have a Medical Staff Association.  Thanks to the Internet and some pretty good search engines, it didn’t take long.

I discussed my request for privileges with the Chief of Staff, in particular newborn circumcision, which I’ve been doing since 1979. Nobody here does them, currently the procedure would involve a 2 hour car trip each way.  And the hospital lacks the equipment.  Happy to offer the service for the growing segment wishing an 8th day procedure, I said “No problem,” such tools, now all disposable, come cheap.  We talked briefly about the various techniques; I use the Mogen and the Gomco.

In the afternoon, I went net browsing for those tools, and found, to my dismay, my usual medical equipment distributor’s website blocked.

Some hospital networks block certain sites, and for good reason; but this one I couldn’t figure out, so I resolved to check when I got back to my quarters.

That website I found blocked, even outside the hospital. I went to a competitor’s website and found 3 and 4 figure prices.  I gasped, and went to Ebay, and found what I would need for less than 1/100th of the first set of prices.

They can put the whole program together for less than $200. On the other hand, I might donate the equipment.

 

I heard “20” used as a verb

May 31, 2017

The patients with brains that disturb?

We don’t kick them out to the curb

We can keep them from harm

With the medicine’s charm

And here we make 20 a verb

 

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

Over the course of a quarter century, I got used to rising before 6:00AM, so that I could round at up to 3 hospitals and arrive at clinic in time to see patients starting at 9:00AM. Eventually I found I moved much more efficiently in the mornings, and as the decades went by my physiology embraced the change into a morning person.

I still get up early, even when I can walk to work at one hospital and round under the same roof where I do clinic; even when I don’t have any work in the morning. Today, before I could go to work, I had to stop at the bank and open an account.  I needed the account so I could pay for professional liability insurance automatically.  The bank didn’t open till 9:30.  So I felt like I was playing hooky.

The extremely personable young woman at the bank looked at my passport and did a double take. “You’re an American?”

I nodded. “I thought my accent would have given me away,” I said.  Although, because it hadn’t, I suspect that my accent is changing without any conscious effort.

I deposited most of my cash. With the exception of the Laundromat, I have been able to do all my transactions via credit card.

But the 8 page form for professional liability insurance asked for all the professional liability carriers I’ve had. Thirty-five years of medical practice has included a lot of carriers, as well as 8 years of coverage by the Federal Tort Claims Act.  I called Bethany; we compiled that data last year for credentialing elsewhere, and within an hour she’d found it.

At noon I walked over to one of the Chinese restaurants.

All medical facilities need meetings so that small problems don’t become big problems. In the Indian Health Service, the entire hospital did nothing but meetings on Thursdays.  Other places allotted an hour, usually over lunch.  When I worked in Utqiaviq (the Inuit village formerly known as Barrow) we met every weekday for an hour.  In more than one place, I got to see the dysfunction that results from eliminating weekly doctors’ meetings.

Today I joined the medical staff for their Tuesday meeting. We started at 3:00PM.  The laughter and warmth that filled the room for the next hour could only come from a group with extremely high morale.  I didn’t have much to add; as a locums I could genuinely say that I don’t have a dog in the fight.  But I got to ask a number of questions.  One of which followed the use of 20 as a verb.

A “20” refers to involuntary hold when psychiatric factors render a patient dangerous to themselves or others. I learned about the process of how to make it happen.

All societies have an obligation to take care of their mentally ill, those disabled by a dysfunctional thought process.   Free societies must balance personal rights against the need to protect people from the psychotic.  Most states limit the time the physician can hold a person against their will to 48 hours, this part of Canada allows for 72 hours.

Bear season: the people can fight back

May 30, 2017

Out here we’ve plenty of bear.

But we go out whenever we dare.

We won’t bring to ruin

An innocent bruin.

So we lock up our dumpsters with care. 

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

Right now this part of British Columbia finds itself in the middle of bear season, meaning that for a few short weeks the people get to fight back. All the dumpsters in town have bear-resistant closures and signs that urge the lock up, because “A fed bear is a dead bear.”  I find no open trash barrels anywhere; those containers have a very clever opening system too small for a bear to get a paw into.

With as many of the bruins as inhabit the area, I would expect more conflicts with the people. Such, however, occur rarely.  The ecosystem also supports mountain lions, wolves, coyotes, moose, elk, and deer.  Though few people talk about hunting elk, many talk about moose and caribou and deer.  Surprisingly few talk about bear hunts.

I still don’t have everything I need to start seeing patients. I must obtain professional liability insurance, and to do that I must have a bank account for automatic withdrawal.  And none of the banks were opened today.  I got the form filled out, with the exception of that one number.

So tomorrow I’ll come in after 930AM, when the banks open.

I started learning the Electronic Medical Record (EMR) system, my 15th in the last 30 months.  I enjoyed seeing Mickey Mouse appear as the test patient; he has played that role in a lot of EMRs that I’ve learned.  Some places have his correct birthdate, May 15 1928.  They list his spouse, Minnie, and some include his felinophobia (fear of cats) on the problem list.  His medication list has included citalopram (an anti-depressant) more consistently than any other medication.

I heard that a doctor put together this EMR, but I don’t know how to verify that assertion. If so, I can hope that it functions.

It will have to be very good to beat New Zealand’s MedTech32.

I’m licensed in British Columbia

May 28, 2017

They don’t give out my license on paper

I hope it won’t turn into vapor

For it’s up in the Cloud

And now I’m allowed

To take the next step in this caper.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since then I’ve worked a few times each in Alaska, Nebraska, and Iowa; I finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, about to get a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I haven’t written about my progress getting licensure in Canada since October 2015, when I sent my packet to PhysiciansApply.ca. Much has happened since, and the hypothetical start date kept receding like a mirage.  About the beginning of this year, it got fixed at May 29.

With no exceptions, every Canadian I’ve talked to has been polite, friendly, and helpful; if not knowledgeable they knew exactly the person for me to talk to. I suspect that the bewildering regulations frustrate them as much as they frustrated me.

I flew into Vancouver Thursday for the last 2 items: my work permit and my license. I took a risk coming to the airport without the work permit, but I needn’t have worried.  The polite, friendly immigration officer at one point reassured me that there was no way he would send me back, as I had made it my mission to help the people of northern BC, and I had all my documents (about a centimeter thick).  I had budgeted the entire day for the process, but he had me out before 1:00PM, on my way to a nice hotel room, where later I would toss and turn the entire night, wondering what the face-to-face interview with the College of Physicians and Surgeons of British Columbia would be about.

Rural health facilities find recruiting doctors difficult. While a lot of doctors can be happy with their work anywhere, most docs (not me) have spouses who prefer the amenities of bigger cities.  Though, strangely, early on I rejected a couple of opportunities in Vancouver.

Again, I needn’t have given so much energy to the interview process. It went smoothly and professionally.  I learned about the licensing process for BC, the strictness of the rules involved with the time allotment.  And I got to talk about my goals.

American doctors love to hate the Canadian system that American liberals love, and neither knows much about it. I want to find out about it from first-hand experience, and to be able to discuss it intelligently.

And the moose hunting is way better in Northern British Columbia than it is in Iowa.

Thus I found myself Friday morning walking away from a beautiful building in the heart of a vital, bustling, energetic city with my provisional British Columbia medical license not in my backpack but somewhere up in the cloud. The College of Physicians and Surgeons of BC doesn’t give out paper licenses anymore: they send an electronic file.

It felt a little anticlimactic, but any effort stretched over two years with thousands of emails would.

 

 

 

How did those samples find me?

May 11, 2017

The samples can help people quit
Without the nicotine fit
Tobacco detox
In a little brown box
Came free, and it made quite a hit.

 

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

 

About ten days ago I found a box on my desk, sturdy cardboard, about 6 inches on a side. It held Chantix samples from Glaxo, Smith, Kline.
I hadn’t asked for the samples, I’d signed no papers for them, and I have no idea how GSK knew where I am. After all, I’ve only been here since February.
And they were the right samples to treat exactly one patient: a starter pack, because abruptly starting full dose Chantix risks major side effects, and two months follow-up therapy. Chantix turns out to work better in real life than it did in the lab; it works more consistently than anything besides quitting cold turkey.
The first patient of the day came in for other things (and gave me permission to write what I’ve written). But just like I do for everyone else, I asked if he smoked.
And, indeed he does.
I used to lecture people on the evils of smoking. By now, though, everyone already knows all the bad things about tobacco. Lecturing only brings antagonism into the relationship; “educating” the patient can thinly mask judging the patient.
These days I use a script from Motivational Interviewing, a technique that capitalizes on ambivalence. I hold my two forefingers a foot apart, and I ask, “On a scale of 1 to 10, where 1 means you’re not ready to quit, and 10 means you’re ready right now, how ready are you to quit?” If they say 1 or 10, I stop. For any other number, I ask, “Why not 2?” Mostly the smokers don’t get the question, and will tell me the bad things about tobacco. I interrupt them, explain that they weren’t ready for the question, and ask them the 3 best things about tobacco. When the patient understands what I’m asking, they mostly talk about stress relief, anxiety, and habit. A few talk about taste. One said “Breakfast, lunch, and dinner.” After they tell me their favorite things about tobacco, I give them a blank stare for 3 seconds, then change the subject. The idea of Motivational Interviewing is to get the patient to think.
But this patient gave me an enthusiastic 10. I don’t get many of those, just like I don’t get many 1s. And he’d done well with Chantix in the past. In fact, he wanted me to give him a prescription for Chantix. “I’ll do better than that,” I said, “I will give you the Chantix.” And 90 second later I reappeared with the samples.
He already knew how to use them, and he already knew about side effects.
I couldn’t think of a more appropriate way to use the samples. Tobacco makes any other medical problem worse.
I enjoy helping people, but certain parts of my work bring me disproportionate pleasure. A low B12, a high TSH, or curing someone by stopping their statin makes my day.
This one came close.

Reflections on medical frauds

May 8, 2017

The system is inherently flawed

They want me to sign and to nod

They have no excuse

It’s all billing abuse

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

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

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

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

“Yeah.”

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

The line went dead.

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

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

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

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

 

The thrills of cerumen and B12 deficiency

April 23, 2017

Real flu has cough, fever, and ache

And I know just the pill you can take

And then there’s the test,

It’s good but not best

But a decision it sure helps me make.

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

I had a good week in Clarinda.

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

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

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

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

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

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

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

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

 

 

 

I take call and end up a patient.

April 23, 2017

At the end, it wasn’t a stroke

It was gone when I awoke

The symptoms were brief

Avoiding much grief

And I got to tell a crude joke.

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

 

Tuesday evening while on call, I got up to play Scrabble and I couldn’t make my right leg work. It didn’t feel heavy, numb or weak; it felt too light so that any effort to move it got exaggerated.   I sat down to do a neurologic exam on myself.  I found nothing other than my right leg ataxia.  I called Bethany from the next room, and told her the situation.  She helped me dress, and drove me to the ER.

The ARNP covering the ER did the same neuro exam I did, which wasn’t impressive until I demonstrated my gait.

She did all the right tests. The first EKG showed an old heart attack, which disappeared with proper lead placement.

She also found a heart murmur.  It hadn’t been present 5 years ago, but the PA at the VA found it a couple of months ago, and I called her attention to it.

My blood work had no surprises. She offered me the choice of staying in Clarinda or going into Council Bluffs, and I chose to go.  In terms of game theory, if something happened in the middle of the night, I wanted to be close enough for timely intervention.

In the process I had to make arrangements for someone else to take call.

I napped off and on for the ambulance ride, which almost got derailed twice by herds of deer. I bypassed the ER at Jennie Edmundson Hospital.  At 2:00 AM I had gotten settled, my IV had given me a couple of quarts, the second set of labs had come back and I’d had a good visit with the hospitalist ARNP.  Just before being tucked in, I offered the nurses a choice between a clean joke, a clean joke with a bad word, or a dirty joke.  They chose the last option, and I gave them the funniest crude joke in my large arsenal.

I don’t get to tell that joke as a physician, no matter how funny it is. But, as a patient, I can get away with it.  The punch line drew gales of laughter.

By then, motor control of my right leg was functioning at about 90%.

I slept for a couple of hours and had breakfast.

The neurologist arrived, and with economy of motion, did a thorough exam. He advised an aspirin a day and starting a low dose migraine medication.

The morning parade of tests started. By the time Bethany arrived I had done the basic neurologic exam six times and the symptoms had resolved except for the funny feeling inside my head.

I had an ultrasound of my neck, a consultation with the dietician (whom I amazed with my six pieces of fruit a day and my two ounces of salmon at breakfast), a consultation with the Occupational Therapist, and then the Piece de Resistance, the MRI. In between, I napped because I’d slept so lousy.

The hospital feeds its patients on the room service system; I ordered a lunch of soup, sandwich, and fruit, and within a half hour a young Guatemalan arrived with the food. We had a brief conversation in Spanish, I introduced my wife.

And we waited. The hospitalist came back, and went over the results.  Ultrasound demonstrated clean carotids (neck arteries).   The MRI didn’t show anything conclusive.  He also recommended an aspirin a day.

We waited for echocardiogram results. The hospital public address system announced a severe thunderstorm warning, and then a tornado watch in effect till 10PM.  The internet and the TV weather agreed that severe weather approached from the west.  At 4:45PM we decided to leave before the storm arrived, without the echocardiogram results.  We didn’t want to spend the night in the hospital, nor did we want to risk hitting deer on the way back to Clarinda.

Bethany drove. We enjoyed dramatic skies and listened to a Continuing Medical Education CD.  We ate at Clarinda’s premiere restaurant, J Bruner’s, ordering off the appetizer menu.

I returned to work the next day, the episode completely resolved, making it a transient ischemic attack (TIA), also call a reversible ischemic neurologic event (RIND).  Except I noticed my handwriting was much clearer.

I don’t think anyone else noticed.