This year’s first Arctic day seeing patients

October 22, 2017

The one forty-five didn’t show

Perhaps the wind and the snow

Made him think twice

About going out on the ice

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

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

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

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

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Back in the Arctic

October 17, 2017

We ignored the things with the wheels

We set out with our toes and our heels

In the wind and the rain

The pleasure to gain

From watching the antics of seals.

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

I am back on the fringe of the 21st century, in a town considerably closer to Russia than to the state capital, inside the Arctic Circle.  You can get here by air. If you come by land, you’d better come in the winter via dog sled or snow machine.  If you come by sea, you’d better come during the summer.

Alaska Natives, Inuit and Yupik, comprise the majority of the population. Most of the calories come from hunting and fishing.

Town life has centered on the waterfront for millennia; boats full of fish or beluga hauled out to start the drying process. But with the passage of time came automobiles, ATVs and motorcycles, and with vehicles came dust, so that food preservation moved away from town.  (A similar problem happened in Barrow, and now most summer fish and game drying takes place in Old Barrow, about 5 miles outside of town.)

Now some of the streets are paved, the water comes right to the sea wall, with a generous sidewalk for pedestrians.

The town has plenty of stop signs and no stop lights. Pedestrians move constantly.  With traffic this thin, people think nothing of stopping in the middle of the road to converse with a friend.

We landed in the early morning dark in a combi, a jet that has cargo in the front and passengers in the back. We walked across the tarmac with the wind and the rain cold in our faces, and listened to people talking about how warm the weather has been the last dozen years.  At the hospital we met two of the doctors and had a small breakfast.  By the time that the black night sky started to gray, we settled into the hotel to nap.

We are so far north and so far west that the sun doesn’t come up till 10:00AM and doesn’t go down till 7:00PM.

We took advantage of the hotel Sunday brunch, looking out over an arm of the Arctic Ocean. We watched seals playing and hunting; I had a cup of caffeinated coffee to help me past the ravages of jet lag.

At 1:00PM I put my sweater on under my waterproof camo jacket and we went out on foot. We timed the walk to the hospital, and we found the Chinese restaurants, grocery store, cell phone shop, post office, police station, and the apartment building where we’ll stay.  We walked in the wind and the rain along the pedestrian path overlooking the water so that we could watch the seals.

If you can’t have a good time in bad weather, you need more practice.

Fixing a calf cramp

October 9, 2017

Type and cross has a 2 hour lead

So if a transfusion the patient might need

Stay 2 units ahead

So they don’t end up dead

If the gut gives rise to a bleed

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 just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

“Always stay 2 units ahead of a GI bleeder,” they said in med school and again in residency. Many years and much experience has not diminished that truism, which to this day shines as an example of game theory.  It means that when a patient loses blood from anywhere in the gut, from the esophagus (swallow tube) to the rectum, that the physician must stay prepared to transfuse 2 units (a liter, close to a quart) of blood.

One can’t transfuse blood without first typing and cross-matching the blood, a complicated lab procedure that takes 2 hours. (For one extreme trauma patient in another country, I ordered the hospital’s entire stock of 5 units of O negative blood, the so-called universal donor type.  But that country has a very different legal climate, and I had no other options.)  You can lose the patient in the time it takes to do the test.

This weekend, I had a patient come in with profuse painless blood in the stool. My small rural hospital has a very limited blood bank, and the ride to the referral hospital realistically takes 2 hours.  I explained to the patient that transferring a stable patient beats transferring an unstable patient, and asked for permission to write about the case from the perspective of how doctors make decisions.  She gave me permission to publish the entire case, and pointed out that Facebook would probably have her room number before she arrived at the referral center.

(Her family history has a disease so rare that to name it would name the patient.)

The mathematical discipline of game theory has a whole branch dealing with games of incomplete and imperfect information. The real world of medicine deals with those circumstances.  I have to live with the limit of what can be known in the time allotted in the place where I work.  I know I never have the whole story and that patients never give a completely accurate history.  I have to work with what I get.

Thus I deal with the certainty of uncertainty.  I can’t know if the patient’s bleeding will worsen or stop by itself, nor if problems will arise during transport.  I have to look at probabilities ranging from worst to best case scenarios.

The paramedics arrived, and greeted the patient by name. Everyone knows everyone here.  As the patient shifted from the gurney to the stretcher, a cramp seized her leg, and she asked the paramedic to massage her calf.

“I can make that cramp go away,” I announced, perhaps with too much assurance. But I took the outside of the middle of the patient’s upper lip as close to the nose as I could, between my thumb and forefinger, and squeezed.  Fifteen seconds later, her calf cramp disappeared.

I think that I unduly impressed the nurses and paramedics,

I learned that acupressure trick early in my career, but I don’t remember where or when. Probably before I learned to stay 2 units ahead of a GI bleeder.

 

The impossibility of scheduling call

September 27, 2017

We know that it’s always our fate,

When the call makes us work late

And our faculties sour

Because of the hour

And it’s really the call that we hate.

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 just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

I took call yesterday. The ER load included 7 patients, all of them legitimately ill.  The five who came after clinic closed arrived at intervals of 2-3 hours.

One patient ended up in surgery.

One, so ill as to necessitate transfer to a higher level of care, needed my presence in the ER as the evaluation proceeded.  While the steady rain fell, the hours clicked off from 3:00 till 6:00, and the results came back from lab and x-ray, I chatted with patient and family members.

One family member (not the patient) told me about breaking her pelvis barrel racing, a women’s rodeo event involving riding a horse as fast as possible around three barrels set in a triangle in a rodeo arena. From my experience in western Nebraska, I already knew that the more time a person spends around horses, the more bones break.  But then she revealed she stayed in the saddle.  “They called it an ‘open-book’ type fracture,” she said, and pulled a copy of the x-ray up on her phone.  The g-forces involved in a tight circle had ripped the bones asunder.  I asked about osteoporosis, and she shook her head, producing another cell phone image showing her on her horse, her face distorted in agony.  When I handed the device back, she pushed a few buttons more and showed me the post-operative x-ray, which included hardware sufficient to stabilize a brick building in an earthquake zone.

I told her I write a blog, noted that as she wasn’t the patient that HIPAA didn’t apply, but nonetheless I wouldn’t write about her without her permission. “Go ahead,” she said, “I’m already a case study at the University of Iowa.”

When I compiled all the result, the subsequent transfer process went well with the patient leaving less than two hours after I asked for the lab tech to be called back in.

In a situation where doc-to-doc communication can mean the difference between life and death, and with an approaching shift change, I had to generate a note to go with the patient, and, in this case, it had to be a Word document. My usual stellar typing performance deteriorates with sleep deprivation, and proofreading showed I’d dropped about half my t’s.

Another patient came in with ten minutes left on my shift, again needing lab and x-ray. Not used to handing patients off, I met with the doc coming on.  We had a passionate discussion about how we love our work, but we hate call.

And really, without call the facility probably wouldn’t need me. The average patient flow in the ER doesn’t justify the expense of a dedicated ER staff.  Game theory predicts the impossibility of scheduling with imperfect and incomplete information. Nonetheless, illness doesn’t punch a time clock.

Shipping a patient: difficult, not impossible

September 22, 2017

There’s a thing or two that I’ve found

By plane, by chopper, or ground,

To move a patient who’s sick

I prefer it be quick

So as to arrive safe and sound.

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 just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

3:00PM: within 30 seconds of meeting the patient I know he’s sicker than he thought, and within a minute and a half I know he belongs not in the clinic, but in the ER. (He gave me permission to write the information in this blog.)

Then I think to ask the nurse, “Wait. I’m on call.  Which means that I’m covering ER, right?”  She nods.

In the current jargon of real-world medicine, the word “dump” means transferring a patient to another service without proper work-up. In this case, though,  I can’t call it a dump if I hand off to myself.

While I wait for the ER gurney I finish my exam, and get as much history as I can.

Two nurses, pulled from the inpatient service to ER, arrive to transport the patient. I hand them a list of lab and x-ray requests and IV orders, and return to the other walk-in patients on my schedule.

3:40 PM: I quick step to radiology to look at images.  In the ER the nurses hand me copies of the lab results, giving me the start of a diagnosis and confirming that the patient needs an ICU.  I discuss findings with the patient and family.  I strongly recommend transfer.  They request a hospital 3 ½ hours distant.

4:00 PM: I weave through the hospital switchboard and phone tree to the consultant’s phone crew, who use a handset that renders speech almost unintelligible.  The consultant is not available.  Would I prefer to wait for the nurse, to leave a voice mail, or to provide a call back number?  I ask for the nurse.

4:10 PM: I run through the case with the nurse, who puts me on hold.

4:20PM PM: I present the patient to the consultant.  I run through the presentation, context, past medical history, lab, x-ray, and my working diagnosis.  I finish with a request to transfer the patient, and the consultant agrees.

In 21st century USA, a doctor cannot legally transfer a patient without a physician accepting the transfer.

4:30 PM: back in the ER to get consent-to-transfer signed.

4:50 PM: the accepting hospital calls to tell us they won’t have a bed available till tomorrow.

The nurses tell me if the patient needs fluids during transfer, we’ll need a Paramedic crew out of Sioux City, because no nurse can’t be found to accompany the patient.

I think that they want me to back off on the IV fluids, but I can’t.

Return to ER: I advise a transfer a hospital two hours closer. The patient and family agree.

5:00 PM: I have the hospital operator put my call-back number into the consultant’s pager, asking how long I should wait before calling back.  The hospital operator assures me she rechecks every 15 minutes.

The nurses point out that if I ask for a helicopter I can get the patient to the destination a lot faster. I look at the ground-transport time from Sioux City (90 minutes) and then the time to hospital, 1 1/2 to 3 1/2 hours.  I agree to the helicopter.

5:10 PM: The closer consultant calls.  My cell phone has enough signal strength to ring but not enough to keep from terminating the conversation.  The nurses usher me to a spot by a window, and I call the consultant back.

5:15 PM: I reach the consultant, who agrees transfer is appropriate, but tells me I have to call the hospitalist.

I call the hospital back to try for the hospitalist.

I didn’t ask for the helicopter lightly.  In this case the geography and gravity of the situation changes the risk/benefit ratio.

5:20 PM: the hospitalist picks up. I make my presentation, with updated vital signs and report on response to treatment.  He accepts the transfer.

5:30 PM: in the ER with the patient (who looks better but not well) and family again, I outline the progress and have them sign an updated consent-for-transfer specifying a new accepting physician and hospital.

I make small talk in the ER, then wander back to the nurses’ station.

5:45 PM: I ask, “When is the chopper due?”

The nurse shrugs. “They said 20 minutes 25 minutes ago.”

5:50 PM: the helicopter crew arrives, with a small bag of Dove chocolates.

I make sure they take the necessary papers with them.

At five minutes to six, the sweet thump-thump of the rotors reaches my ears. In less than twenty minutes, I know, the patient will have access to the personnel and services he needs.

The nurses note that I don’t look upset.  I tell them it might have taken 3 hours, but I’ve seen worse.

The click of a linguistic show-off

August 29, 2017

That language didn’t come quick

And my accent is still a bit thick

It might sound like a crow cough

But I am a show off

And used my Naa Dene click.

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 spoke a lot of Spanish in my quarter-century working in Sioux City. Eventually, my accent settled into the developing Spanish accent of the area.  On taking care of a Hispanic patient for the first time, I frequently got the question, “Where are you from?”  And I’d reply that I’m American.

The query, “Yes, but what is your nationality?” invariably followed.

(Regretfully, people of Asian descent in both Canada and the US face the same question; the questioner usually implies that a person with a particular appearance must be from somewhere else.)

Sometimes I use the word Gabacho (a derogatory term for white Americans, heard mostly in the Midwest). Sometimes I’ll talk about my grandparents being from Russia and the Austro-Hungarian Empire.   And sometimes I shrug and say I’m a linguistic showoff, because I am.

If they ask me why I speak Spanish, I just say it’s good business.

Many but not all the Natives from the Bands close to here come from the Naa Dene linguistic tradition. So I greeted one of my patients today with, “Daa natch’eyaa,”  meaning, “How are you?”

“Sa’atch’ee,” came the reply, meaning, I’m fine. As I prepared the injection, he asked, “What kind of white man are you that you speak our language?”

“Aalk’iidaan,” I replied, “Shi naalnish Toohaajaalehidi. A long time ago I worked with the Canoncito Band of Navajo.”

Navajo language belongs in the same group as Naa Dene, with some important differences.

Being a linguistic showoff, though, I couldn’t stop there. I asked the Naa Dene word for goat.

It took me three weeks to learn the first consonant in that Navajo word. The linguists use the ! to represent the click, to the best of my knowledge, the only click outside of Africa.

My patient didn’t want to look surprised when I repeated it accurately, but he did.

 

 

Learning about a new toxic inhalation

August 22, 2017

It’s been quite a while since Yale

Some of my knowledge went stale

For I’ve never been tried

On chlorine dioxide

When it comes to the stuff you inhale.

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.

This town depends on forest products and, to a lesser extent, mining.   Felled trees get trucked or floated to the industrial area just outside of town, to get sawn at the lumber mill or chopped and bleached at the pulp mill.  The wood useful for neither process gets burned as biofuel at an electric plant.

The pulp mill operates 50 weeks per year, with a two-week shut down at the end of each summer for preventive maintenance and cleaning. The usual work force gets supplemented by short-term workers and contractors with their crews.

The cadre of workers may have experience, but all change involves chaos, and from chaos comes hurt.

Today, I saw a patient who had inhaled chlorine dioxide, ClO2, referred to by its local name, clowtwo (rhymes with crow brew) the day before, and gave me permission to write a good deal more than I have.

Decades ago, I worked in a town that relied on the meat-packing business. That industry requires a lot of refrigeration, which in turn depends on ammonia.  We did a lot of workman’s compensation medicine at the time, and one day I had four workers brought in simultaneously for ammonia inhalation, from a refrigerant leak.

Had I been asked, I would have diverted all 4 patients to the Emergency Room, but I hadn’t had the chance. I immediately had one nurse start oxygen, another nurse call for 2 ambulances, and a third nurse inject steroids.

When I called the ER to request a transfer, I could say, honestly, that they were breathing just fine and wondering why I was so worried. By the time they arrived at the emergency room, all 4 were starting to drown in their own fluids.  They all survived, after close to a week in the ICU.

I dealt effectively with a tough situation because I had read up on the effects of ammonia on the lungs beforehand, and I knew how dangerous it could be.

In this case, I knew a good deal more about chlorine inhalation, because of its use in WWI, but I didn’t know about chlorine dioxide and I hadn’t read up on it. The patient helped me along as I clicked my way through the Net, giving me the benefit of his experience.

 

Why I Came, and Can I Fix the American System When I Get Back?

August 14, 2017

My reasons? I’ve got quite a few

I didn’t want to say I withdrew

My application

But my rationalization

Got me to work with the right crew.

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.

The patient (who gave me permission to write a good deal more about her than I have) asked why I came to British Columbia.

A lot of people ask me that question, and I truncate the truth, too complex for brevity. In no particular order:  I have a thick stubborn streak.  I had a tiger by the tail: see the project through or have to say that I’d withdrawn an application for licensure.  I wanted to spend more of my time taking care of patients and less time at meaningless but marginally lucrative mouse clicking.  I have a sense of adventure.  I wanted to know the truth behind what US doctors vilify and US liberals champion but neither have any experience or knowledge about.

There are more.

So I just said, “I wanted to know find out about the Canadian system.”

As I opened the door she asked, “So, when you get home, are you going to fix the American system?” I said, “No, but the first step is educating the American docs. And I’m not sure they’ll believe me.”

Actually, I don’t think the liberals will believe me, either.

+=+=+=

Last night the smoke from the forest fires drifted into town. The dramatic evening sky progressed from intriguing to eerie.  Finally, darkness fell, thick and hard, two hours early.  The smell of smoke kept me from falling asleep.  This morning we watched the news for two hours to see how close the fires are.

We don’t want the fires to come this way. Too close and the town dies from lack of wood.  Much too close and the whole city goes up in flames.  I wouldn’t want to have to evacuate, and I don’t know which way we would go.

We’re seeing an increase respiratory problems from the smoke. Some people have come in from BC’s largest city, Prince George, because of air quality.

=+=+=+=

Last time I was on call, I saw 14 patients, and 3 diagnoses accounted for 13 of them: back pain, abdominal pain, and left facial pain. The only one not covered by those three complaints came in before the others, and left, cured.

 

Contentment and birthday pizza

August 13, 2017

At the end of a beautiful day,

We caught the sun’s reddened ray

We snacked on raspberries,

Pizza and cherries

And then we went on our way.

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.

Different organizations have different ways of celebrating birthdays. During my New Mexico years, I got used to bringing food for the clinic when I marked a change in age.  I continued the habit into private practice and Community health.  Mostly, I had Bethany pick out a good selection from Panera.

One of my colleagues ticked just a little closer to 40 last week, and a selection of cupcakes appeared in the clinic. And, at the last-minute, he and his wife put together a pizza-based gathering after work.

Bethany and I drove out to his house at the outskirts of town. He has had black bear, grizzly bear, deer, moose, wolves, and caribou in his back yard.  But on this particular evening we contented ourselves with stories of close wildlife encounters.

The docs drove up, one by one. Before the noise disrupted conversation, I showed off my trick of sharpening knives on the back of a ceramic plate.  Till the pizza arrived, we snacked on chips, and sweet cherries freshly picked in southern British Columbia.

We ate the pizza at leisure. I’ve written in the past about how doctors tend to bolt their food because we never know when we’re going to get called away.  These physicians know how to work hard but more than that they know how not to overwork.  We enjoyed our food.  We chatted.  Topics included economics, politics, horticulture, wildlife, and medicine.  We recounted various places we’d been.  Perhaps because of my country of origin, we had some lively history discussions, fortunately none of them mentioned the Fenian raids, where renegade Americans tried to invade Canada shortly after the Civil War.

The day waned, and I relaxed. Forest fire smoke takes the clarity from the air but it makes spectacular sunsets.  In this case, the solar disc reddened well above the horizon, while cool evening breezes mixed in with the heat of the day.  I reclined after a good day at the clinic and in the late stages of a great summer.  I had worked but not too hard, I had eaten but not too much.  I had chatted knowledgeably but without pedantry.  I had sharpened the knives, but no one cut themselves.

I wallowed in contentment, thoroughly in the moment.

After a bit we toured the grounds. We picked raspberries and ate them immediately.  We saw the Saskatoon berry bush, trampled by the visiting bear.  I looked for the peach tree I had seen earlier.

And when the mosquitos came out, we said good night.

 

 

Patient Transfer and Push-back

August 12, 2017

The specialist just needed a chance

To vent his frustration and rants

Just as expected,

The referral’s accepted

Sorta what I thought in advance.

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 listen to the subspecialist’s voice on the phone, and I can hear the overwork through the bluster, asking me what I think he can do for the patient that I can’t.

The local term for what he is giving me is “push-back.”

I got a lot of it from Alaska Native Medical Center (ANMC) in Anchorage when I would try to transfer a patient. Even before I would pick up the phone, I knew I’d be attempting to enlist the cooperation of a physician close to burnout, with a service already bursting at the seams, analogous to pouring gallons into quarts.

In another century, in another country, I faced push-back from every rung of the hierarchic ladder at the academic hospital, when I had to ship out a patient with Reye’s syndrome. With vomiting, altered mental status and a swollen liver, I had made the diagnosis in less than a minute, and spent two hours proving it with lab, while late evening ticked into early morning. The medical student, intern, and resident all tried to block the transfer, but passed my call up the food chain.  The presentation to the chief resident, polished by the first three layers, included answers to the questions posed by the underlings in a coherent, rapid fire fashion.  In the silence of a 3 second pause I could hear something in him break, a resignation to the inevitable, and then he said, “Well, I supposed I’m going to have to accept the transfer.”

(I’ve not seen a case of Reye’s syndrome before or since; it disappeared when we stopped giving children aspirin. That particular patient recovered completely.)

I never ran into push-back in New Zealand. The physicians at the university hospital sounded fresh and cheerful every time I called.  But they have a different system; following the online flowchart weeded out the majority of unnecessary calls.

Today I catch the subspecialist in at the university hospital fresh, in the middle of the afternoon.  He fires off a list of questions, interspersed with complaints of thinly spread resources.  When he pauses, I confess I use a whiff of sarcasm when I say, “Would you like me to answer, or would you like to keep going?”

I figured out, early in my private practice years, that I spent more time and energy trying to avoid work than actually doing it, and I quit pushing back the ER docs when they called me to admit a doctorless patient. Because I built up good will, about every 7 years, when I really needed to, I could dodge an admission.

Between my sarcasm and the chance to rant uninterrupted, the subspecialist loses momentum, and in the silence over the phone, I can hear something break. Resignation replaces resentment when he accepts the admission.

I later learn he has a reputation as a good, caring, skillful physician in a badly understaffed situation.

I feel for him. I hope he doesn’t burn out.