Posts Tagged ‘addictions’

Remembrance Day, without cognitive drift

November 19, 2018

Consider the dragons you feed.

When it comes to the smoking of weed

Add up the expense.

It doesn’t make sense

But neither does booze, you’ll concede

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

Canada celebrated Remembrance Day last week.

In elementary school we learned about Armistice Day, and few people now remember that WWI fighting stopped at the 11th minute of the 11th hour of the 11th day of the 11th month of 1918.

Armistice Day still exists, but the celebration has morphed. The US celebrates Veterans’ Day, and Canada has Remembrance Day.  The clinic and a lot of the town’s businesses closed.  I even bought a fake poppy and pinned it on my lab coat the Friday before.

The day after, I came back to work rested and refreshed. I had a fantastic morning.

Not a single patient that I attended before noon used marijuana. Perhaps some people can get high responsibly, but the people who get sick don’t know when they’ve had enough tobacco, alcohol, or cannabis.  And now that Canada has legalized weed, heavy hemp usage has become an increasing factor in anxiety, depression, insomnia, erectile dysfunction, testosterone deficiency (“low T”), falls, and accidents.  Poor short-term memory and impaired ability to deal with numbers makes history taking and patient education problematic.  So my morning went more easily.

If a patient’s story keeps changing in terms of concrete details such as numbers, dates, and times, the cognitive drift clues me in to probable intoxication.

Alcohol and tobacco, and increasingly marijuana, of course, give me job security. I had patients that morning with insight into their problems, taking steps to deal with their addictions.

Almost every patient with an addiction knows they have a problem before they walk through the clinic door. By the very definition, an addict continues an addiction despite negative consequences.  But few realize the financial costs.  So I added up the addictive costs for a patient and came to a total over $15,000.  (That approach failed when caring for a tobacco-chewing Inuk who spent less than $100/year on the habit.)

Every patient gets subjected to observational neurology. I look, I listen, I touch, and I smell.  The basic examination of the nervous system starts when the patient comes into the room.  The neurologists will tell you that watching a person walk and listening to them talk will get you through 90% of the diagnostic possibilities.  I used those skills last week to make a tentative diagnosis, and I look forward to seeing a patient improve.




Small non-miracles

November 1, 2018

I don’t believe in my aura

At least I don’t any more-a

I can’t tell you why

A bird will fly and not die

When I pick it up from the floor-a

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

I took care of a patient today with a physiologically unlikely (but not, as it turned out, impossible) complaint. Before I had the chance to research, and while I kept my skepticism concealed, I established rapport with the patient and, in the process, learned to use a medical instrument I’d never seen before.

When the world started the change to digital, I ran into problems.  I stopped the first digital watch I bought in 1980, and kept stopping them for another 10 years.  After that they didn’t stop so much as the batteries died quickly.

When I came off the Acoma Reservation in 1985, the first electronic cash register I encountered malfunctioned at my approach.  I attributed the stoppage to the inherent fragility of new technology, but the trend continued for another 12 years.

Our youngest daughter ran into the same problems and to this day kills digital watches.

I do not believe people have auras, and thus I find it hard to account for the fact that digital devices used to break down consistently in my presence.

But, to build rapport, I told these stories to my patient, who also stops digital watches.

She has a way with animals, and she catches birds with her hands.

I recounted the time that a bird flew into our picture window, while our children, age 7, 9, and 11 watched.  The bird dropped to the patio, and the kids immediately demanded that I, the doctor, go try to revive the apparently dead bird.  I picked it up, it regained conciousness, and flew away.   The kids showed no surprise.  I tried not to, either.

My patient told me that I’d done the right thing.  A stunned bird righted will generally come to, but if left supine will die.  If your patience wears out before the bird flies, she said, place it upright in a box or other structure that will keep it upright, and most will live to fly.

I hadn’t known that. I asked for, and received permission to put that information in my blog.


I came to realize that taking call has all the earmarks of an addictive process, and wrote about it in another forum.  Other people, besides doctors, take call.  In the context of symptoms that could be psychological or physiological, I talk to patients about what addictive processes have in common.  This particular patient agreed vigorously.  I printed out my essay and handed it over.

I had call the night before, and it went badly.  I have suffered adverse consequences because of call, and missed time with my family.  Call has made me physically ill.  As the years go on, I spend more and more time recovering from call.

But I keep doing it.

I felt like the biggest hypocrite in northern British Columbia.

Road trip 4: with my brother in Woodstock

November 3, 2014

If addiction is the sum of all fears,
Do we wait till it all comes to tears?
Or is our prediction
Of a bad prediliction
Towards the whiskeys, the wines, and the beers?

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I used vacation time to do two short assignments in Petersburg, Alaska. Currently on a road trip, I left the Community Health Center last month because of a troubled Electronic Medical Record (EMR) system.
I dropped my sister, niece, wife, and stepmother at the Long Island Railroad station, put my brother’s address into Samantha, my GPS, and set off for upstate New York.
My brother, an artist, recently moved into a very nice house near Woodstock. As the wind picked up and the temperature dropped, we walked around his acres. I gave him my amateur pomologist’s opinion of his aging apple trees. I looked at the standing but dead timber around the property and did some onsite surface archaeology. His girlfriend joined in the discussion of planting fruit trees.
We talked about our careers over sushi in town. Freelancing for an artist bears similarities to locum tenens for a doctor, especially in terms of contract negotiation. We agreed that inability to at least appear to be willing to walk away from a deal ruins a negotiating position. I detailed my recent untoward experience with a recruiter low on professionalism.
My brother recently studied hand anatomy. I brought to his attention how much all seven siblings’ hands resemble each other.
Later, at his house, we sipped at small quantities of very expensive bourbon, and brought up the subject of addictive disorders in our own lives and in our family.
The key to recognition of an addiction is continuance of a behavior despite adverse consequences, especially missing social commitments.
I put forth my analysis of taking call as an addiction for doctors. He pointed out, correctly, that insight rarely creeps into addicts’ lives. Then we tried to figure out which behaviors qualify as addictions.
I talked about a friend who works as an alcoholic; his business relies on selling wine and spirits. He starts drinking when he gets to work and stops when he gets home; it doesn’t interfere with his work, but, still, that doesn’t keep him from the diagnosis. And it might make bring new depth to the term workaholic.
Our conversation turned to sociopaths and the problems society has from those who enjoy other people’s pain. Probably those people tend to certain professions, including police, corrections, military, and, regretfully, medicine.
Then I started telling jokes. All seven siblings share a quirky, off-the-wall sense of humor; we bring quick, easy laughs to all conversations. My ability to remember and effectively tell jokes remains as rare in our family as it does in general.

What’s a doctor to do without acamprosate? Drama and irony, alcoholism and manic-depression, and strength versus resilience

May 5, 2011

When you stop to add up the score

My day is never a bore.

    It was my impression

    That manic-depression

Affected patients one out of four.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  On sabbatical and back from the brink of burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  Currently I’m finishing an assignment in Matakana and Wellsford, north of Auckland, on the North Island of New Zealand.

I have a touchstone question to diagnose bipolar disease, which used to be called manic-depression.  I ask, “Have you ever had an episode lasting at least four days during which you felt great, got a lot done, slept less than four hours a night and didn’t miss the sleep?”

I find the disease equally common, under-diagnosed, and hard to treat.  Those affected tend to reject medication, because doing away with their depression means doing away with their euphoria; people don’t want to exorcise the devil if it means they can’t dance with the angel.

Doctors talking amongst themselves will shake their heads and talk about the co-morbidities of bipolarity, especially alcoholism, drug abuse, and schizophrenia.

Alcoholism romping through a family by itself causes enough damage, linking it to Richter-scale mood swings shatters family structures and warps children’s personalities.

One quarter of the patients I cared for today came to me because of the direct or indirect effects of bipolar illness.  If you want to understand something, you have to understand its context; though one patient at a time has an appointment, each exists in a family.  The best treatment I can recommend frequently comes down to Alcoholics Anonymous, Alanon, and Alateen.

“Strong” children, the ones who can hold a family together before the age of fourteen, alarm me because strength acquired early comes at the expense of resilience.  Those children who take on the super-responsibility of keeping things together in the face of chaos in later life tend to snap rather than bounce back from life’s inevitable traumas.

Until recently, AA stood as the best, most-tested treatment for alcoholism.  In the US, Campral (acamprosate) has shown itself safe and effective for a number of addictive disorders, including gambling.  Best if used with a support group like Alcoholics Anonymous, it established itself as the drug of choice.  It does not exist in New Zealand, and I had to discuss that with more than one patient.

The absence of Campral as a therapeutic alternative constitutes my sole disagreement with New Zealand’s formulary.

I cannot recommend people get the medication outside the country, and Internet pharmacies are notorious for inaccuracies and counterfeits; I do not know of a single reliable one.  Yet I found myself listening to my patients talk, and saying that I couldn’t imagine a jury convicting someone for trying to bring Campral in illegally.

Throughout the morning I watched the agony caused by self-destructive behavior, dramatic in a family member and ironic in the patient.

But I had energy left over when I finished my clinic; my schedule permitted me enough time to talk with patients.  I drove away with Bethany in the afternoon to visit the Kauri Museum, dedicated to the spectacular tree that dominated the north part of New Zealand before logging destroyed the forests.

I’m working on my resilience.