Posts Tagged ‘alcohol withdrawal’

The Risks of Patient Transport: playing games of imperfect and incomplete information

January 6, 2017

Blog 2017 January 5, 2017

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 a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

In private practice last century, I got a call from a mother of a sick child late in the afternoon. Despite a tight schedule, I told her to bring the kid up, now, and I would attend to the problem.  In a hurry, and in traffic, her car collided with another.  No injuries resulted, but since then I have always kept in mind the risk of patient transport.

Many Alaskans live in places inaccessible by road. You can get there by plane, train, or boat, or, in winter, by snow machine.  Rivers thus become highways, not barriers.  The geographical imperative colors medical decision making.

Game theory forms the basis for making a lot of choices, and medicine becomes a microcosm of the human condition. Any course of action carries a risk, and, at the same time, not taking that action carries a risk.  As physicians, we deal with the real world when we play games with incomplete and imperfect information.

Consider, for example, a hypothetical patient in alcohol withdrawal. At first evaluation, I would generate a CIWA (Clinical Institute Withdrawal Assessment) score based on temperature, blood pressure, pulse, sweating, agitation, irritability, restlessness, memory, and overactive sensations of touch, hearing, and sight.  In Iowa, where transport to the hospital carries almost no risk, a score above 8 would mean hospitalization.  But here, a score of 25 would make me consider sending the patient to Ketchikan by boat.

Not so fast. If the wind keeps the floatplane from flying, it whips up whitecaps on the water.  I would have to consider the risk of drowning 5 people.

I also have to consider the risk that the patient, once stabilized in the Ketchikan ER to a score less than 8, might be discharged to the streets.

In such a case, I would do as much as I could (in this example, fluids, vitamins, and sedatives in the family that includes Valium, Xanax, and Ativan), keep the patient in my ER, and, if I could get the CIWA score under 8, get twice daily follow ups for a couple of weeks.

When we refer patients out, they usually go to Ketchikan, but our obstetrics patients go to Sitka. Major illness requiring subspecialists could go to Seattle or Anchorage.  And every transport carries a risk.


Mail the patient in a cardboard box.

March 15, 2016

The ER doc said with a growl

“Should I cry fish, fair or foul?’

For after the collision

How do I make a decision

About a Boreal Owl?”

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, travelled 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 am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.


At morning rounds on Monday we gathered to go over the cases from Friday and the weekend. Including the doctors and the representatives from Mental Health, Pharmacy, Nursing, Physical Therapy, and Social Services, I counted 15.

Drama and irony run rampant in those stories, and, as always, drugs and alcohol provided the majority of the good stuff. But the best patient had been brought in after a collision with a car, and still had a pulse, and was eventually identified (with the help of the internet) as a Boreal Owl.  The calls flew back and forth, and the experts agreed that the best course of action included punching holes in a cardboard box and send the owl via mail.  Which is perfectly legal.

I hope HIPAA doesn’t apply to wild animals.

In general I don’t like prescribing controlled substances, and, when I do, I prescribe in small numbers. Though I dislike the benzodiazepines (a family which includes Valium, Xanax, Ativan, Miltown, and Klonipin) the most, I acknowledge they have their uses.  In fact, I would have difficulty caring for inpatient alcohol withdrawal without them.  I find few other uses for them, such as claustrophobia for an MRI or fear of flying, but I in fact found a reason to prescribe 6 pills of one (but I won’t say for what or for whom).

I decided a long time ago that I’m a lousy judge of character. Too many people have fooled me too many times.  So I ask for a urine drug screen on everyone who asks me for a controlled substance, and even a few who don’t.  I find about 50% surprises.

As everywhere, drug seekers come to the facility hoping to get substances with which to get high or to resell. As it turned out today I did a lot of physical exams for people wanting to get into drug or alcohol rehab, and I was able to pick the diagnosis of Health Seeking Behavior.

And today the people wanting to quit tobacco outnumbered the ones who wanted to continue.

Mission creep: a census grows and genomics comes now comes retail

April 10, 2013

Does a thousand seem likes it’s cheap?

Beware the assumptions you keep.

Don’t think that it’s strange,

There will always be change,

And ever the mission will creep. 

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

Last night I took the handoff for a hospital census of 4, a record low since I started with this clinic.  Even though I arrived for rounds before 7:00AM, that number had grown by 3.  I whizzed through two admissions, three patients with kidney failure, one each with alcohol withdrawal and complex pneumonia, five diabetics, a newborn, and two coronary patients.  (Do the math, you’ll figure out that a patient rarely enters the hospital with one problem.)

The longer a person lives, the richer their life story; and in the course of half an hour I had the treat of listening to a wonderful family history unfolding over the course of three generations.  I left them hope that the specialist would be able to cure the problem. 

But I squandered 15 minutes trying to educate a nurse, who overhearing me speak Spanish, made disparaging remarks about immigrants. 

Still I finished at the one hospital before ten.  At the second hospital, still in the throes of transition from paper charts to a new Electronic Medical Record (EMR) system, I only had to round on the pediatric floor, and I held onto hope of getting to the office early. 

I discovered an EMR quirk: one now needs 9 keystrokes, not 1, to edit a dictation.

I got to the office early, but not nearly as early as I’d hoped.

After half an hour of buffing documentation and messages, I attended what had been billed as a provider meeting.

The man who brought the lunch didn’t pitch a drug but a lab test.  Using material on a cotton swab from the inside of the mouth, for a mere thousand dollars, his company can provide us with genomic information about how fast or slow a person might metabolize a range of medications. 

For example, a single standard 30mg dose of codeine provides good pain relief for 80% of the population.   But 20% of population lacks the enzyme to convert codeine to morphine; for those people, codeine might suppress a cough but won’t relieve pain.  The super enzyme found in 1 in 3 Somalis converts 100% of the codeine to morphine on the first pass through the liver, enough to kill half of those who try it.    

Our clinic prescribes almost no codeine.  For whom will the test bring a thousand dollars with of benefit when it comes to choosing an antidepressant, antipsychotic, or ADHD medication?  We requested more information.

I didn’t ask the larger question: how long will it be till an entire genomic sequencing becomes available for that price? 

Mission creep remains a permanent fixture on the constantly shifting medical landscape.  Whether a doctor deals with a growing census, or a company sells technologic improvements, we all know that the world, at the end of the day, will not be the world we had at the beginning.



Blog reopened after a year on the job.

July 5, 2012

I find my job a delight

Even when working at night

On this I won’t budge,

I’m a doc, not a judge,

And there’s always something to write.

I have decided to reopen my blog after a year’s absence.  I miss writing, and I miss the immediacy that comes to my life when I go through my day thinking about my post.  I’ve been at my new job a year now.

My workplace runs on teamwork; I’ve never been any place where people seek out so many opportunities to help their coworkers. 

Our patients have few resources; 50% have no insurance, 35% have Medicare or Medicaid, and 15% have commercial health insurance.

I see a lot of schizophrenics, people whom our society has failed badly.   I’m sure if they could push a button and come to a closer contact with reality, they would.  As it is, they hear voices when they don’t take their meds and sometimes even when they do.  An extraordinary number also carry a diagnosis of bipolar.  Almost all smoke, and, given enough time, almost all develop insulin dependent diabetes. 

I find it easy to avoid judging the schizophrenics; they did not ask for their problems.  The less I judge my patients, the more energy I have at the end of the day.

We have so many patients from Ethiopia and Somalia that we have Oromo, Amharic, and Somali translators, and I’ve learned to say Hello, How are you, and Thank you.  Mostly hardworking, family oriented people, they came here after unspeakable horrors.

Many of the people who come to my clinic have been behind bars.  I don’t ask them why.  After all, I did not train as a judge.  Those folks have done their time and my job, as I see it, demands that I focus on what can be done in the future, not what has already passed. 

I start Mondays with hospital rounds till noon, then clinic till 8:00PM.  I’m on call 35 Tuesdays per year.  Most call nights I work straight through till after 9:00 PM.  I start Wednesdays at 7:00AM and finish around 6:00PM. 

I have Thursday off, along with Friday, Saturday and Sunday if I don’t have call.  I still put in 48 hours weekly.

Yet I worked no more than two days a week in the last six weeks, which I found unfulfilling.  I arrive at work Monday mornings cheerful and happy to be back, and I go home on Wednesdays ready for the weekend.

Saturday/Sunday call a year ago ran to fewer than 10 patients between two hospitals, but practice growth led to mission creep, and now a hospital census can run upwards of three dozen.  At any one time, we usually have three patients in liver failure, and three in active alcohol withdrawal.  A surprising number of non-alcoholics end up with cirrhosis.  About half our hospital patients also show up on the dialysis service.  Mental health census averages 5. 

Our patients get sicker younger than any patient population I’ve seen before, which surprisingly, gives me more hope.