Locks on the Clothes, Keys on the Shoelace: the dress of a millwright.

July 9, 2017

The millwrights has many a key

For the mill cuts up many a tree

On the machine go the locks

Preventing visits to docs

And keeping the workplace accident-free

 

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.

Thursday I took care of 17 patients. One pediatric patient required all my patience, skill, and accumulated experience to get the job done without alienating the kid.  The oldest patients barely qualified as septuagenarians.

I wrote a lot of prescriptions for blood pressure drugs.

I used my deep-breathing techniques on three patients to bring blood pressures into the acceptable range.

Though only 15% of Canadians smoke, the nicotine addicted comprised more than half my patients.

I wrote several back-to-work slips, all employees in the timber industry.

I cared for even more millwrights and former millwrights. Changing logs into useable products involves a lot of dangerous machinery, and the people who fix the machinery come in loaded with padlocks on their clothing.  They lock a machine before they work on it, to make sure it won’t start accidentally.  Spare keys get carried where they can’t get lost, such as tied into shoe laces.  During the work day, a “whistle” signals a need for a millwright.

One of my patients in frustration said, “Can you give us a referral to see a specialist we can actually see?’ and we laughed after I asked for and received permission to use the quote in my blog. While I know my way around the human body, and most of the things that go wrong with it, I don’t know the local medical community.  Yet the permanent doctors trained near here, and know the consultants personally.

There’s also a province-wide network providing phone-in advice for docs . The consultants get paid on a fee-for-service basis; the patient has a unique identifying number, and the doc has a bunch of unique numbers (I have 8), one of which is the right one to use.  Computer algorithms coordinate compensation.

Time off from clinic for Canada Day

July 6, 2017

They celebrate the First of July

Canada’s birthday, that’s why.

On the way back from there

We saw two black bear

And gave Tim Horton’s a try

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 Day, this year representing the 150th anniversary of the Confederation of  colonies Nova Scotia, New Brunswick, and Canada, passed largely unnoticed in the US, but well celebrated here in Canada.

Bethany and I slept in and strolled over to the Rec Center for the free barbecue, the third so far this summer. But the demographics of the gathering, not the free food, impressed me the most.

Canada can boast the world’s most ethnically diverse population. We saw a lot of Native faces, and a good mix of Chinese and South Asians.  Everyone got along with the famous Canadian politeness.

This part of British Columbia sports a younger-than-provincial-average population. We saw easily a hundred children with almost as many strollers as baby bumps.

Consider how this mix contrasts with southwest Iowa.

Iowa, the grayest State in the Union, has the highest percentages of septuagenarians, octogenarians, nonagenarians, and centenarians. Within the last year, during my two assignments in the southwest quadrant of my home state I had the daily privilege of taking care of a lot of very old, very spry people.  They had wonderful stories to tell.  A few had survived the Great Influenza of 1918.

We eyed the line for the burgers and brats, then strolled over to the skate park to watch youngsters ride bikes and skateboards around obstacles including ramps, stairs, railings, and benches. One young cyclist took a spill.  He got up and tried to ride the bicycle but couldn’t.  He walked it over to his parents , whom we recognized.

Bethany looked over at me and asked if I wanted to fix the bike. I smiled, and we walked over to the trio and explained I had fixed bicycles professionally through premed.  Sure enough, the brakes wouldn’t let go.  I quickly realized the front wheel had done a complete 360, twisting the brake cables, easy enough to rotate the other direction.

The day after Canada Day we took a drive to mile marker 0 of the Alaska Highway in Dawson Creek.   Highway 97 winds through pine-and-poplar forests, over rivers large and small.  I hadn’t seen any agricultural development for a hundred kilometers.  But we crossed a mountain pass, with tortured rocks exposed in the road cuts, and came into a valley on with lush meadows, herds of cattle and horses, an occasional flock of sheep and the odd goat here and there.  From time to time we saw fenced enclosures with hundreds of round hay bales stacked two deep.

Chetwynd hosts the annual World’s Championship Chainsaw Carving contest; competitors leave behind piles of sawdust and exquisite carving. We stopped into the visitors’ centre.

Of course they asked us where we’re from. We explained that most Americans don’t know where Iowa is, having flown over it but unable to name any of the 7 states that share a border.  Surprisingly, the staffers have a friend who goes to University of South Dakota in Vermillion.

In Dawson Creek we took the requisite selfies at the marker for the beginning of the Alaska Highway, 75 years old this year, and lunched on sushi.

On the way back through Chetwynd, we stopped at a Tim Horton’s, a Canadian restaurant chain a notch or two better than McDonald’s, for dessert. We couldn’t stand the thought of visiting Canada without at least trying such a national institution.

We took our time on the way back, curious about the various human installations that appeared out of the wilderness on either side of the highway, mostly to do with the energy industry.

Just 15 kilometers shy of our hotel, two black bears crossed the road, taking their time, but not quite slow enough to get out the camera.

 

Lower blood pressure with deep breathing

July 5, 2017

It’s a technique, and I don’t mean to brag

But when the smoker lights the first fag

And breathes deep and slow

Though the smoke is the foe

They’re champs at that very first drag.

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 see a good number of people with high blood pressure, some better controlled than others. If the pressure is too high, I repeat the reading.  A second round of measurement less than 5 minutes after the first will give a falsely elevated reading.

Most of those with hypertension (a blood pressure greater than 140/90) smoke tobacco and drink more than healthy amounts of alcohol. I point out to the smokers that they have a valuable tool, that they didn’t realize they had.

I was still working for the Indian Health Service when I had a conversation with the worst nicotine addict I ever met. She had quit 4 packs per day about 10 years prior.  Half the relaxation of the cigarette, she said, is the deep breathing technique that goes to taking the first drag.  Every meditation system in the world stresses the deep breathing that all smokers have taught themselves.

Breathing can change blood pressure a lot. The FDA approved a device to teach people to slow their breathing down; the studies showed it safe and effective for blood pressure control.

So I tell the patient to pretend they’re taking the first puff of the day, to breathe slow and deep, and I breathe with them.

I repeat the blood pressure measurement after 6 deep, slow breaths, and almost always the top number drops by 30 points and the bottom by 15, good enough for most people. Whether the improvement is adequate or inadequate, I tell the patient to breathe slow and deep for 20 minutes a day, whether in one chunk or twenty.  For those current smokers, I point out that they could get half the calming effect of tobacco just by doing the breathing exercise that they already know how to do.

+=+=+=

I had call last night. With light traffic in the ER I managed to get back to the hotel early, but I got called back at 10.

As far north as we are, I walked to the hospital with the setting sun in my eyes. Forty-five minutes later, I walked back in the twilight, thinking that I should have brought the bear spray with me.  I crossed the highway with literally not a single vehicle moving.

Learning about the timber industry

June 28, 2017

The market for trees comes and goes,

A boom and a bust, I suppose

At the end of the caper

Logs get turned into paper

And you can watch as the baby tree grows.

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.

My education in the tree industry proceeds.

When the US economy tanked in 2008, this town felt the impact. The housing bubble burst, the demand for new houses dropped and with it the demand for lumber.  At the same time, electronic publishing cut into newspapers and other print media, so that the demand for wood pulp went down, and the local jobs evaporated.  Some people stayed, but more than half left.

The market for tree products has gradually improved since. Logs get chipped, the chips get bleached and cleaned and cooked to make pulp, which gets spread into sheets, dried, and sent to China.  Rumor has it that China turns it into toilet paper and sends it back, but undoubtedly it has more uses.

The trees around here suffered from the mountain pine beetle a few years ago. Normally that insect just takes out trees about 80 years old, but fire suppression and lack of logging shifted the ratio of old trees to total trees.  Then the area had a succession of warm winters with a resultant improvement in larva survival.  The warm winters went with dry summers which weakened all the trees, which then succumbed to the beetles.

Some trees stay green for a few years after they’ve effectively died, and get used for lumber. Dead trees retain lumber value for several years, and after that they become fodder for the pulp mills.  But those who log must, by law, replant.

The only tree planter I’ve met so far has been doing other work this century, but replanting involves a shovel and remains unmechanized.

Once cut and trimmed, logs may be trucked directly to the mill, or otherwise moved to a body of water. Secured with cables into rafts or contained with booms, they might move more than 200 miles before meeting the saw or the chipper.

Lake Williston, the largest reservoir in British Columbia and the 7th largest in the world, transports a lot of floating timber, even in the winter, when an icebreaker moves the logs.

And everywhere that logs move, people move with them. I see the consequences when humans face the tyranny of Newtonian physics:  a body in motion tends to remain in motion, a body at rest tends to remain at rest, and two bodies cannot occupy the same place at the same time.

June 25, 2017

They come in, right off the street

The problem it seems, is the feet

And then when the pain

Makes them complain

Orthotics just can’t be beat.

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 have really bad ankles. I started with flat feet as a child, and things haven’t gotten better in the last 60 years.  Now I wear stiff hiking boots with orthotics you can, literally, drive nails with.  They keep me going.

A fair number of my patients, no matter where I go, come in with foot problems.

Most “ingrown” toenails result from people cutting a corner of the big toenail too short, temporarily relieving the pain but setting themselves up for worse problem when the nail grows out, cutting into the flesh. More than half the time the original problem stems from shoes functionally too small.  I tell people to keep their nails trimmed.  With a flair of showmanship I predict I’ll find a hole worn in their shoe lining from the big toenail, then I tell them to file a bevel into the end of the nail, making it both more flexible and easier to trim when it grows out.

Those with plantar fasciitis start the first step of the day OK, then the pain hits. But it gets better as the day wears on.  At the end of the day, they might sit and relax for 20 minutes but when they stand up they face excruciating pain.  I teach them stretching exercises, encourage them to lose weight, and advise new footwear.

Most WalMarts have a Dr. Scholl’s display; those orthotics (shoe inserts) can be the first step away from the pain. But if they don’t work, I recommend the podiatrist, or, sometimes, the orthotist, a person who does nothing but make orthotics.

The patient gave me permission to say that when I told her to take off her shoes and stand up, her arches sagged to the floor. They looked just like mine.

Then I talked about how I felt the first day I put my feet into the solid inserts. I walked away with a gait 30 years younger, my back straighter.

 

Dislocated thumbs and warmth in the ER

June 24, 2017

To the ER the injuries come,

So I just took hold of the thumb

Yes, dislocated

But a technique underrated

Includes no drugs to make the hand numb

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.

Over the years I’ve learned at least 8 different ways to put a dislocated shoulder back into place (medicalese: reduce the subluxation).   My favorite remains the one I learned in the parking lot of the hospital on my last day of residency.  I met one of the emergency docs coming in as I was going out for the last time.  He told me he’d learned the technique that involved no drugs, bandages, tape, buckets of sand, or force, and he showed it to me.  I use it to this day.

It failed only once, when in another clinic in another city a very muscular young man suffered a dislocated shoulder in the course of an electrical injury.

Last night, on call, for the first time in my career I faced a patient with a dislocated thumb (the patient gave permission to include a good deal more information than I have). I looked at the x-ray, I reviewed the anatomy, and put together a plan.  But I’d never done one before so I felt I should at least speak with someone with more experience before I tried it.  I put out a call to a consultant orthopedist and I waited.

And I waited.

One of my colleagues who had done several of the procedures, just back from an ambulance run came striding through. I told him the plan, and he gave me the nod.

I had the patient give me the thumbs up sign. I grasped the digit, and we started to chat.  As the patient relaxed, I took the weight of the hand, and, eventually, the arm.  After 5 minutes, supporting the forearm with my other hand, I let go.  Using patience and gravity, the thumb had slid back into place, with no drugs, no violence, and no clunk.

Just the way I like it.

_*_*_*

Injured people rarely come into the ER alone. Some of my patients have problems so difficult to look at that you wouldn’t see them in a horror movie.   The visual impact can jar friends and relatives into free displays of affection.  But during a recent night on call, I witnessed a kiss so astounding that the warmth flooded the ER and so memorable I had to comment on it.  I kept doing what I had to do, thinking all the while that so much love must make a difference in the healing process.

 

An ambulance ride to town and back

June 22, 2017

The patient gave us a scare
We did as much as we dare
A long ways we did ride
While it was raining outside
And I spotted a young dead black bear.

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 ride in the back of the ambulance with the patient, a nurse, and an EMT.
I can’t talk about the patient or the patient’s problem, except to say its seriousness demanded the presence of a doctor and a nurse on the ambulance.
Sending both of us put a significant crimp on the healthcare manpower of the town, as well as leaving the municipality without ambulance coverage.
I have ridden in ambulances before, but during the last century. Common IV pumps remained a dream then, and I adjusted the IV drip rate using my wrist watch. Ambulances ran a lower profile at the time, and I couldn’t stand up while we rode; nor did I have a seat belt.
I got little precious sleep in the wind-up to this transfer, and we left in the rain while the beginnings of daylight brought color to the world.
Between the bumps in the road, the need for speed, and my position sitting sideways, after 40 minutes I begin to fear meditation failure ending in vomit, and I request a basin. The nurse, a woman of immense and invaluable experience, knows exactly where to reach for it.
I see nothing of the beautiful landscape as we proceed. Mostly I keep my eyes closed and my breathing deep and slow while I imagine worst-case scenarios, and how I would proceed if they happened.
Three times the nurse asks for permission to medicate the patient, and I consent. We keep our eyes on the instrument that measures blood oxygenation, blood pressure, pulse, and breathing rate.
A few miles out of the city the road acquires more lanes and divides, and the traffic picks up. The change in siren pattern tells me when we blast through intersections.
Ten minutes from the University hospital I look at the patient and the word “deterioration” springs to mind. But when we wheel into the brightly-lit, well-staffed, fully-equipped Emergency Room I know that we’ve done our job.
Just before we depart, one of the EMTs gets a call to transport a patient from the city back to their outlying hospital. In the time it takes to ready the next patient, we decide to go to breakfast, and the choice is easy: Tim Horton’s.
“Timmy’s,” as the Canadians call it, with higher quality than McDonald’s, not quite as fancy as Perkins, has outlets across Canada. I’d think they’d want to invade the US.
We drive a few blocks in traffic denser than anything I’ve seen for weeks. We park in a position of dubious legality, knowing ambulances never get parking tickets. The four of us stand in line, a little too polite to walk up to order. But at the end we walk out with our food, past a rapidly growing line. I carry a cookie and a yogurt parfait, hoping the way back will go smoother.
We pick up the new patient, the transport does not justify lights and sirens. I get to ride in the front.
On the way back I learn about the pulp industry, how ambulance services get billed, how EMT shifts get arranged, and some of the history of the town. I comment that although I see signs cautioning wildlife corridor I don’t see dead animals on the side of the road.
The EMT explains that Animal Control removes the carcasses quickly, so that local predators don’t hang out on the pavement and cause more problems.
And, just like that, we pass a road-kill bear.

Trying to figure out what “call” means

June 21, 2017

When my weekend came to an end

A patient off we did send

With findings so rare

It gave us a scare

And help we needed to mend. 

 

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.

 

People can use the same word and mean different things, different words to mean the same thing, or even the same word in different contexts to mean different things.

Doctors use the term “call” when talking about coverage after hours and on weekends, but what does that word “call” really mean?

In Utgqiavik, the town formerly known as Barrow, it never meant anything other than 12 hours. I have been places where holiday call meant ten times that.  Depending on the location, weekend call might start on Friday or Saturday morning.  Or it could include staffing a Saturday clinic.  Sometimes it meant ER coverage only.  For a couple of decades I had to field calls from nursing homes, patients, ERs and hospital inpatient units as well as obstetrical duties.  For one former employer, if I drew the duty, I could count on sprinting between hospitals to admit patients till midnight, and a minimum of one phone call every 45 minutes requiring critical decision-making.

In New Zealand, when I worked for a North Island outfit, “call” meant staying overnight in the clinic.

On one particularly memorable assignment, it meant nothing other than having my name on a calendar slot. I had protested the marginal cell coverage at my dwelling.  Administration told me not to worry, in the event of a disaster the Sheriff knew where he could find me.

I write this while on weekend call. Sunday morning dawned very early and very clear.

During my 23 years in private practice, the docs wouldn’t talk about how the weekend went until afterwards. The same superstitious factors leading to that custom led to the many Emergency Rooms that banned the “Q word” (quiet).

What does weekend call mean here? Starts at 8:00AM Friday, ends at 8:00AM Monday, followed by a day off.

Now post call, I can say I cared for 3 people who, for one reason or another, didn’t have a chart in the local electronic Medical Record. I never cared for more than 12 people in one 24 hour period.  Several times, on the verge of leaving for the apartment, I asked people on the way in if they had come for emergency services.

At the end, a patient arrived with an extremely rare problem, so serious I called a colleague for help, and ended up riding in the ambulance to the medical center.

Power failure in the hospital

June 18, 2017

Right now we don’t really know
What caused the transformer to blow
But it wasn’t a squirrel
That put the grid in a whirl
Our best suspect now is a crow.

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.

Quite some time ago I worked with the Canoncito Band of Navajo; the place is now called by its proper Dine name, Toohaajilehi. At that time, most people lived in traditional hogans, round or 8-sided structures with a smoke hole in the middle of the roof. Eighty-five percent had no running water; a few of those households accessed electricity through their truck battery. With notoriously unreliable electricity, we had an average of 6 outages a day, and no way to sustain the new-fangled computers then slowly invading medicine.
We knew how to handle electric failure; every exam room had a window that we could open in the summer, and all of us knew how to layer up in the winter. If I needed the microscope I used the battery-powered otoscope for light. We kept our records on paper.
Two summers ago I worked in suburban Pennsylvania. In a thickly settled, industrialized area, one would expect reliable electricity. Nonetheless the Urgent Care outfit I worked for kept its clinics supplied with back-up generators, wired only to the computer system. On average, once a week the power outage lasted longer than the half-hour’s worth of diesel in the generator’s tank.
Last winter I worked in a coastal Alaska town with a modern grid and a hydroelectric plant. But in that relatively dry spell while I was there, the lake level dropped, the hydroelectric failed. The hospital’s emergency generator kicked in, but it also supplied juice for the town. Unfortunately the noise of the power plant invaded my office and exam rooms.
Friday the power flickered once as I came on call, then failed completely. The hospital’s back-up power system kicked in, supplying critical parts of the ER, but, strangely, only two computers at the inpatient nurses’ station. Notification came that full restoration would take 6 hours. Staffers called scheduled patients to rebook.
Different outfits react differently to power outages, but almost all look manic and giggly for the first half hour. Here the grins lasted a good deal longer, and no one got grumpy. But they did tell me such occurrences come rarely these days.
In the early afternoon I got the Emergency doctor’s computer hooked into the active portion of the back-up grid. I did the documentation from the few patients I’d seen thus far, and generated a couple of discharge summaries.
The power came back on in the late afternoon, and I attended patients, one by one, who came to the ER.
When I got home in the evening, Bethany told me that the best guess so far blamed a curious crow in a transformer. I haven’t been able to confirm the story, but, knowing how squirrels can knock out power in the US, it wouldn’t surprise me.

Spinal manipulation and other tools

June 17, 2017

When it helps, it’s ever so nice

And for me, it’s not about price

For the old spinal crunch

Can sure help a bunch

I’ll manipulate, but not more than twice.

 

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.

For the most part I approach medicine in a go-by-the-book fashion. But I keep an open mind, and I try to keep more than a passing acquaintance with what has been called “fringe medicine.”

I took a month’s course in acupuncture as a senior in medical school, but it would take decades and much research it to gain anything like acceptance. We now have more evidence to support the treatment of chronic pain with acupuncture than with opioids (also known as narcotics), yet many more docs use the opioids than the needles.

Honey as a cough suppressant has become a mainstream recommendation.

I went to Michigan State, which has an MD school right next to an Osteopathic school. We shared most of the basic science classes in the first two years, and twelve members of my class demanded teaching in osteopathy.  We met for an hour twice a week in a basement, and we practiced on each other.

In fact, I learned spinal manipulation even before I finished premed. You could call the crowd I ran with “nerds” or you could note that we shared information whenever we could.  But I learned how to feel where other people hurt, and I learned how to crunch backs.

At Michigan State they taught me when to and when not to use the technique. I also learned what they called “muscle energy” manipulation; the technique is also known as “push-pull” or “strain-counterstrain.” You can improve range of motion if you move the affected part to the barrier, then have the patient do an isometric contraction away from the barrier.  I use the technique, for example, after prolonged immobilization in a cast renders a limb stiff.  But it also works when spasm limits mobility.

(Properly done the technique is more complicated than I have described. Please do not try it at home.)

When our oldest daughter contemplated medical school, I steered her towards the DO track; those tools come in handy in primary care. And so far this week I have used them several times, making the patients better before they got out the door, and teaching them how to use the tool in the future.

But the power of manipulation must be used with respect.

In another clinic in another town in another country, a while ago a patient came to me with classical back pain. His chiropractor twice had helped a lot but only for a couple of days.  I crunched him twice, with good relief.  But when he came back the third time, I stuck to my guns, and, rather than manipulating his spine, I sent him for a CT scan.  I could not have imagined beforehand the very grim diagnosis.