Posts Tagged ‘alcohol’

How to put 75% of the physicians out of a job

November 19, 2018

Perhaps genetic predilection

Could serve for behavior prediction

I’ll make a confession

Like those in my profession

I’m employed because of addictions.

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.

Addictive processes have commonalities. People lose count, they lose control, they fail at trying to set limits, the addiction takes priority over health and family, adverse consequences happen but the behavior continues and continues to demand more and more time as use escalates.

Not surprisingly, addictions account for a disproportionate part of my business.

Fewer than 15% of Canadians smoke, but smokers today make up 75% of my patients.

Most drinkers smoke and most smokers drink, and, not surprisingly, most marijuana users also use tobacco and alcohol.

Long ago I quit trying to get substance abusers to admit to a problem. Most of the time I can get them to tell me about the chaos that envelops them.  When we discuss alcohol, marijuana, or meth, they generally make light of the problem, and I ask, “How’s that working out for you?”

I do not contradict the people who say, “Just fine.”

But I frequently try to get the patient to talk about their goals. And then I ask, “How does $8,000 dollars going every year to tobacco, alcohol, and weed fit in with your plans?”

Those techniques I got from a program called Motivational Interviewing, and, thanks to the wonders of the Internet, it has become available to anyone with a computer. It allows a person to capitalize on someone else’s ambivalence.

I do not expect to see the impact of Motivational Interviewing immediately; doing locum tenens I rarely see the impact at all.

But last week over the course of 2 days, 6 of my patients declared intentions to get clean and sober. Three asked to be sent for counseling, and two have already started going to meetings.

Each one of them comes from a back story of betrayal and abuse, loaded with drama and irony and promises made and broken. If they keep on the path of recovery, they will discover that weaknesses can be strengths and strengths can be weaknesses, depending on application and timing.

I hope this trend continues and spreads. Doing away with addictions could potentially put ¾ of the doctors out of business.

I hope I live long enough to see it happen.

Livers and lotteries

October 26, 2018

You could be a taker or giver
There’s a chance, but only a sliver
You probably won’t pick it
So don’t buy a ticket
Thus to keep a healthier liver.

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.
Abnormal liver tests dominated yesterday’s clinic. Each patient had a different problem, and each went into a different management plan.
The most common liver poisoner, of course, is alcohol. But if a patient credibly claims alcohol avoidance, I have to look for other exposure to alcohol or other organic solvents. I have found a disturbing number of people with medical problems from breathing vapors of Lysol Spray, a product containing 95% alcohol. (Regretfully, many years ago I took care of a patient who later died from liver cirrhosis caused by drinking Lysol Spray.)
Too much food can damage the liver, just like too much alcohol. When rich food has, in the whole of human history, never been so cheap or convenient, NASH, (non-alcoholic steatohepatitis) now ranks second to alcohol for damaging livers. Within the last ten years one of my patients died of cirrhosis caused by overeating.
I still check for hepatitis A, B, and C though a result from those tests hasn’t surprised me for years.
About 1 in 50 people carry the mutation for hemochromatosis, where a person’s DNA fails to code for a signal to quit absorbing iron after having enough. The excess iron ends up in the liver.
Much as a person born with the mutation for continuing iron accumulation after storage reaches saturation, some people don’t know when they’ve had enough alcohol, or food. And some don’t know when they have enough money.
To be rich you must be content with what you have, and, really, without the capacity for contentment a person will always have the drive to acquire more even when not needed.
Even contentment does not suffice to make a person rich. I have met retirees with pensions who have no interest in acquiring more, but they get into trouble precisely because they have enough to keep them from want but they have nothing to do with their time.
The day dominated by liver patients started with news from the US about a lottery jackpot of more than a billion dollars.
At breakfast Bethany and I remarked on the sum, and I said that a pot that large might tempt me to buy a ticket.
Lotteries ruin lives. Losers spend money they can’t afford and find in their losses an excuse to not be happy. Winners gain weight, get divorced, lose their moral compass and see their loved ones die.
So I don’t buy lottery tickets for fear I might win.
But a billion dollars? I could blow it building a medical school to my vision: Hire the most gifted teachers to generate cognitive content for premed and the 2 classroom years, and post online courses at very low cost. Weed excess students by requiring fluency in a second language. Anyone passing Part I of the Boards could apply for a clinical position.
Or, alternatively, I could just keep doing what makes me happy.
And I don’t even have to buy a ticket to do it.

A friend’s death 2: massage

March 13, 2018

With one exception, when I wrote about the death of my brother-in-law, I have opened these posts with a limerick.  Understandably, until now.

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. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, I’m taking a break to welcome a new granddaughter, deal with my wife’s (non-malignant) brain tumor, and attend a friend’s funeral.  Any identifiable patient information has been included with permission.

Physician is a large part of my identity. I observe people wherever I go, I note physical findings.  A stiff gait, poor arm swinging, and a face that doesn’t move normally indicates Parkinson’s disease, even before the tremor.  I call that airport neurology.

In any social gathering, people will come to me for medical advice, and I don’t even try to dodge. Lack of a state medical license limits what I can do out-of-state.  I listen sagely and say the 7 things the doctor always says: nicotine, caffeine, alcohol, overweight, exercise, sleep, and seatbelts.  And, these days, I recommend vitamin D.

None of those who gathered for my friend’s service uses nicotine. Most caffeine users expressed a willingness to taper down to zero and stay caffeine free for two weeks as long as they could do a full dose rechallenge.  Almost all get regular exercise and about half do yoga.  None are overweight, all have conscientious diets, and most do not sleep well.

In our college years, Bob and I hung out in a social group where we did a lot of back rubs; one of us went on to become a licensed massage therapist.

I can feel other people’s pain by touch. Such a talent has a surprisingly wide distribution: almost all massage therapists and chiropractors.  Bob taught me a good deal about finding hot spots in other people’s backs, and what to do about those spots.

I remember early in our friendship, as he leafed through a Playboy magazine, he said something like, “If she doesn’t get that T6 adjusted she’s going to get an ulcer.” I looked, he pointed at the photo of a good-looking young woman’s naked back.  “You look for the ridge-valley sequence,” he said, “And where there’s an interruption, there’s a problem.”

He taught me how to adjust the spine, from the critical vertebra at the base of the skull to the place where the pelvis joins the lumbar spine.

I shudder now to think that I acquired the tools before learning when to use and when not to use them, comparable to giving a 3rd grader a chain saw.  But acquire those tools I did, and when I took the osteopathic manipulative therapy course in med school I had close to a decade of experience.

Over the last 30 years I developed a routine for relaxing the muscles in the upper back and neck, and for most the routine takes 3 minutes. A couple of years ago, at a clinic I will not name, a teenager’s neck muscles (trapezii and paracervicals) melted when I touched them in the initial tactile scouting expedition, cutting 2 minutes and 50 seconds off the routine.

This last weekend, the people I massaged, Bob’s friends and family, relaxed very easily. When I demonstrated the way to relax the muscles without help, I had an audience of half a dozen.

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.

A single digit error explains low patient flow

July 27, 2016

I said to the front office clerk

I hope I’m not being a jerk

Someone who works in hive

Wrote  seven, not five.

Now will you please just send me more work?

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 went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

After two months of no patient care I returned to work three days ago. Patient flow crept in the single digits daily.

Still I had bloggable moments.

We dealt with a cardiac arrest the first day. Doing CPR constitutes a valid workout, and people fatigue so quickly that the guidelines call for a change of personnel every 2 minutes.  My turn came, and the hospital CEO followed me.

For different people with different problems that day I advised drastic alcohol reduction, complete tobacco elimination, good hydration, sleep prioritization, regular exercise, and a return to counseling. I pointed out that marijuana aggravates anxiety, deepens depression, brings on paranoia, and sabotages life goals.

Yesterday we watched through my office window as the crane lowered a new installation, really a prefabricated building with very expensive equipment, into place. The machine, worth dozens of millions of dollars, came down slowly, guided by men in hard hats with ropes.  I recalled my days in construction, when I swept the concrete footing furiously just before the crane lowered the form.  I looked at the odd clods of dirt on the footing and shook my head.  The stucco wall now sits three feet outside my office window, completely obstructing the view, and reflecting the heat from the sun.  I’ve quipped it’s a monochrome mural by a noted abstract artist titled Beige Wall, and offered to forge a Salvador Dali signature on it.

I performed my version of a complete neurologic exam on 4 different patients yesterday; all completely normal. I deal with a lot of patients with headaches, migraines and others.

But I also took care of a very sick patient. At the end of the day, I ordered a lot of lab work, all of which got sent to a reference lab an hour away.  I left my phone number with the techs, telling them that they could text me results without violating HIPAA as long as they didn’t attach a patient name.  And I could do so safely because I only had one patient hospitalized.

Today the low patient flow continued. The new installation required lots of drilling through my office wall.  I fled the intolerable noise to chat with a colleague.  But I also passed a front office staffer at a critical time.  She asked me my UPIN.

Various entities have assigned me various unique identifying numbers, starting with my 9 digit Social Security number. The longest one, with 14 digits, comes from Canada. I gave her the 10 digit number, flippantly, ending with 365.  She frowned.  The one she had on file ended with 367.

That one digit error resulted in no insurance credentialing for 5 companies. The clinic administration worked hard much of the afternoon to try to set things right.

While the drilling in the wall continued.

I thought about the Bob Dylan song, Lily, Rosemary and the Jack of Hearts.

February 24th, 2015, a day that will live in infamy

March 3, 2015

When it comes to the drug they call pot
What is it good for? It’s not.
But they were quick on the draw
To pass a new law
And speed up the memory’s rot.

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 System (EMR) I can get along with. Right now I’m in Nome, Alaska.

Marijuana use runs rampant across the US.

In the early part of the year I asked a patient, a single parent of five and a major pothead, if they would hire a babysitter who got stoned every day, and we agreed that any intoxicant impaired ability to care for children.

My first Monday back brought me to contact with patients running into problems as a direct result of their marijuana abuse.

Mostly hemp excess happens in the context of abuse of other drugs, usually tobacco and alcohol. All three contribute to poor memory, seizures, depression, loss of restful sleep, low testosterone levels (both sexes), low sex drive (both sexes), lowered resistance to infection, poor pain tolerance, social isolation, and irresponsible parenting.

Recently I had a heart-to-heart talk with couples in the maelstrom of dysfunction; the medical problem that brought them in stemmed directly from marijuana abuse. I correctly guessed that both had cold, controlling, distant mothers, and exciting, generous-to-a-fault fathers who failed to follow through on promises and brought repeated disappointments. They readily admitted that each could tell me everything wrong with the other and neither had much of a handle on their own failings. I pointed out that drug abusers can’t exist without enablers, and the cycle can be hard to break because it has roots more than a generation old.

I took a step back and talked about myself. The vast majority of med students, 70%, come from chemically dependent households and most of the rest had other sources of dysfunction in their nurturing families. I skipped the details of my upbringing, but I told them about Alanon and the Adult Children of Alcoholic Parents movement, which use the same 12 steps as Alcoholics Anonymous, and how I went to meetings for 7 years. Every strength is a weakness, every weakness is a strength; it all depends on what you do with them. We agreed that their current approach didn’t work. I replaced a benzodiazapine tranqulizer with Dilantin (most common use=seizure or migraine, but a good second or third choice for almost everything), recommended 12 step meetings for both, and called in Behavioral Health Services.

I learned more about human behavior in dysfunctional families from Alanon than I had from med school.

My last patient requested a back-to-work slip, which I cheerfully supplied. But in the process I uncovered alcohol and marijuana excesses; I accepted at face value the patient’s assertions, and said, “Let me be the first to tell you that nicotine, alcohol, and marijuana will make any medical problem worse and none of them better.”

I could more easily believe that the weed wiped out memory than that all previous docs had missed the chance to educate the patient.

During my two weeks off, the state of Alaska legalized marijuana on February 24th, a date that will live in infamy for those with intact memories, but the pot heads will promptly forget.

I suspect that those in power prefer an apathetic electorate with a poor memory.

Road Trip 5: vegan lunch and free advice

November 5, 2014

Sometimes over coffee or tea
People want my advice, just for free
If they ignore what I say
I ask them to pay
But I’ve never collected a fee.

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.
Wherever I go, people, on finding out my occupation, will ask me for free medical advice. I tell them if they take the advice, it’s free, but if they ignore it, they’ll have to send me payment.
Lunch today was no exception. I won’t go into the details of the case, even though the patient gave the information in public in front of an audience. The gastrointestinal symptoms had persisted for decades.
I always start with a good history, so as we dug into our gluten-free and vegan fare, I asked the basics: when did it start? Where do you feel it? How bad is it? What happens? What is the character of the pain/smell/discharge/problem? If it comes and goes, how long does it last and how often does it happen? What makes it better? What makes it worse? What have you tried that helped? What have you tried that didn’t help?
The luncheon café setting precluded doing any sort of physical exam beyond that inherent in conversation.
I never prescribe medication in such situations, though sometimes I advise the patient check with their doc to discuss lab or drugs.
Mostly I do non-pharmacologic therapy.
I usually start with ABCD: always blame the cotton-pickin’ drug, thus stop nicotine, caffeine, alcohol and any recreational pharmaceuticals. Then I start into the med list.
Most diseases fall into a spectrum of severity, and proper attention to sleep, diet and exercise can shift almost any medical problem into the less severe range. So sections of advice overlap, because nicotine, caffeine, alcohol and recreational chemicals murder sleep. Some fun pharmaceuticals (such as alcohol and marijuana) bring on sleep but suppress the most restful phases, delta and REM. Thus leading to chronic fatigue and loss of emotional resilience, and thus they make any disease state worse. In particular, I said, if the mind stays out of balance, so will the intestine, as all neurotransmitters (chemicals that carry messages in the brain) have receptors in the gut.
I also recommended a week’s trial of the Prune Water Protocol: put a prune in a glass of water and leave it by the side of the sink till you go to bed, then drink the water, eat the prune, and brush your teeth. Repeat twice daily. A lot of chronic digestive problems come down to chronic constipation (usually from incomplete emptying), and I haven’t met a case of non-malignant constipation that resisted the Prune Water Protocol.
The patient may or may not follow my advice, but certainly won’t pay me.

Weird things with pills

July 21, 2013

Some people, while looking for thrills,

Aren’t choosy when it comes to their pills

They get stoned and then drunk,

Or droned and then stunk,

And face horrible hospital bills.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

People do weird things with drugs.

I won’t say where or when this happened.  The patient in the ER claimed to have confused pills (an antidepressant) prescribed for someone else with a common analgesic (ibuprofen), supposedly for joint pains.

The incident happened in the context of partying with friends the day before.  As the gentle interviewing process continued, the number of recreational drugs ingested doubled, then quadrupled.  I didn’t bother to ask about dose; no one can count after they’re high.  Some of those recreational chemicals were legal, some were illegal, some were legal for someone else, and I didn’t want to know who.

Med school trained me to be a doctor, not a judge; HIPAA mandated that any information I get from a patient can’t be revealed to anyone else without their consent, not even to the police.  In fact, if I started to report all the illegal drugs my patients use, I wouldn’t have time to attend to sore throats and runny noses.

But the patient’s story kept changing, not surprising given the degree of intoxication.  The other party in the exam room kept showing me the prescription bottle and saying, “You can really see how someone could make that mistake, can’t you?”

No, I couldn’t.  And I said so.

And as hours passed, the patient’s behavior got more and more bizarre, and less and less congruent with an antidepressant overdose the day before.  Eventually, the patient had a bed in the ICU, nurses had bruises, police arrived and applied handcuffs, large doses of tranquilizers found their way in the bloodstream, and I had spoken with the Clerk of the Court to get a 48-hour hold.

Less than 24 hours later I had the chance to discuss the case with a couple of clinical pharmacists.  We looked at the drug involved and the length of time it takes to clear from the system and the physical findings.  We agreed that the two people had left out large parts of the truth.  I had to admit I had looked at the antidepressant bottle but hadn’t looked at the pills.  Could I vouch that the bottle contained the antidepressant in question?

No, I couldn’t.

For the most part, patients tell me the truth as they see it.  Sometimes they just lie.  The more I thought about it the less I wanted to take the story at face value.  After all, I find it more likely that someone who had just had a “couple” of beers, an unknown amount of marijuana, and a dubious dose of amphetamine would take something else on purpose rather than by accident.

Following Poison Control’s explicit directions, I treated the patient, let time take its course, and watched the patient improve.

Christmas 2012: caution, longer than usual.

December 26, 2012

These things sure shouldn’t come cheap,

The phone, the admit, the beep

One hundred and twenty

Hours seem plenty

To forego quality sleep. 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Christmas falls on a Tuesday this year, so that the holiday call includes everything from Friday at 8:00 AM till Wednesday at 8:00AM. 

My share of the dirty job began well on Friday; I started early, moved efficiently and rounded on twelve at the first hospital, discharging 3.  Our hospital nurse greatly boosted my efficiency by entering orders, filling me in on the patients, researching old charts, and placing calls.  We rounded on three more at the second hospital, finishing rounds well before lunch.

I got to eat a festive meal at the clinic, pizza bought by the providers and managers.  A quick nap in my office chair followed by a couple of hours of paperwork, and a hospital admit through the ER rounded out the afternoon.

Friday night I slept poorly, my sleep ruined by vigilance.  Still I got through rounds by 12:30, then napped well into the afternoon.  After dark, the real work started with admission after admission. 

Three different patients couldn’t talk to me for three different reasons.  Still, it makes the drama and the irony more poignant when I carry on a conversation and have to keep redirecting my comments to the patient.  And I don’t know which strikes harder, doing so with a conscious or an unconscious patient but the contrast in itself brings meaning.

Called in at midnight and back home past one, and hammered by the phone every time I got to REM sleep, I dragged myself into rounds on Saturday morning. 

About 830AM I had trouble keeping my thoughts in my head long enough to write them on an orders sheet, and I simply had to rest.  In a doctor’s dictation room I leaned my head back against the wall.  I crossed my arms and napped for 9 minutes, exiting the real world directly to dreamland and coming back without going through non-dream sleep.  I awakened euphoric.  I finished my rounds by noon and returned home to try to nap again.

Eleven phone calls shattered my siesta till I went to the ER to admit a patient.  I returned to the same hospital at midnight for another admission, and 8 phone calls followed till 6 on Sunday morning, when I gave up trying to sleep.  Only one phone call interrupted my shower. 

Sunday rounds went well and at 3 I signed off to my partner and went to the gym for a workout.  Bethany and I dined out and I crawled into bed early and out early.

On Christmas Eve morning I went back to the gym.  Rounds on 9 patients (with one discharge) followed breakfast out. 

The hospital’s yearly culinary largesse helped keep the good humor of a good night’s sleep, and I finished rounds before noon.  Preemptive napping alternated with beeper traffic punctuated the afternoon till an admission at 500PM and another at 700PM. 

Christmas Eve found me responsible for 20 hospital patients.  Three narcotics abusers had legitimate medical problems requiring narcotics administration.  Three people had pancreatitis.  Two people lied to me about drug use and four others told the truth.  Terrible infections in various states of healing besieged the immune systems of five patients. 

Five phone calls mangled sleep between midnight and 100AM, mostly concerning a psychiatric patient with no medical diagnosis; the question concerned not patient care but which physician should assume title of attending and which consulting.

The morning darkness of the 25th found me in the doctor’s lounge with a census of 11 in one hospital.  For each patient I reviewed vital signs, labs, x-ray reports, consultants’ dictations and the note for the previous day before I entered the room, washed my hands, greeted all present, sat down, asked about symptoms, stood up, listened to heart and lungs and examined what needed examination, sat down again, went over the case so far, and told a joke.  I spoke directly with consultants regarding three.  Another six required discussion with the nursing staff.

Substance abuse, mostly alcohol, runs rampant in patient populations; today I discussed cocaine with twice as many patients as usual.  A substance that leads people to sex work, it also brings on the death of heart tissue at an incongruous young age, which in turns leads me to look at the poetry of pathology. 

I came home at 1230PM and lunched.  I plugged in my phone and lay down, intending to have my standard 18 minute power nap and awakened two hours later, refreshed in body and battery.

We had a birthday dinner with our neighbor.  Bethany came with me when I left for more hospital work at 700PM. 

Every visit with a patient requires documentation.  I found 64 dictations I had to review and edit; about one-third had laughable typos (for example, I said trophic changes at the ankles, and they typed terrific changes at the ankle). 

Just as I finished, I received a beep from the other hospital’s ER.  A young patient required admission.  As I gathered myself, my beeper sounded its cheerful ring again from the other ER; an adult required admission.

I left Bethany in the doctor’s lounge and set off towards the other end of the hospital, 300 yards away.  Cheerful drama and irony followed, and I returned fifty minutes later.

Tired people make mistakes.  I arrived at the other hospital and realized I’d forgotten to download the history and physical I’d just dictated from my pocket machine.   Having Bethany do that for me without orientation and training did not rate the word feasible.

I took the elevator to the fourth floor.  The patient and the family recognized me from a year ago as the doctor who plays with yoyos. 

At 1010 PM we started the cross town drive.  The process of downloading involved 9 distinct steps and a 3-digit code but lasted less than a minute.

In bed an hour later and promptly asleep, vigilance awakened me at 130AM.  I took my own advice to get out of bed and do Something Else if unable to sleep for more than 10 minutes in bed.  Yawning set in an hour later, and I slept solidly till the alarm went off 15 minutes shy of 600AM.

The beeper and phone both went off at 630AM; a patient needed admission through the ER of one of the hospitals, but I had a commitment to a C-section at the other hospital at 700AM.  When mom and baby checked out normal, I called my partners about the admit.

I can’t give details but the fine points of that last admission’s turf question have huge ramifications.  Things settled, I got back in the car at 800AM.

Thus in 120 hours of holiday call, I put in 28 hours in the hospital, and took 161 phone calls.  I got called back in to admit patients 7 times.  I got 17 hours of payback coverage that included an excellent night’s sleep, otherwise my longest uninterrupted slumber was 5 hours.

I’m napping most of the day, and going deer hunting this afternoon.



Retrospective: distilled aphorisms from last summer’s posts

May 22, 2011

It’s been now a year and a day

Since I left near the end of last May

     I’ve bettered my writing

     I’ve weathered weird lighting

And I’m not doing this for the pay.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance back from the verge of burnout, I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and working the last half of a four-week assignment in Waikari, less than an hour from quake-stricken Christchurch, in New Zealand’s South Island. 

My non-compete clause expired yesterday; I went over my posts from that time, and found the following pieces of truth:

One cannot go to discover new adventures without leaving home; mobility must be weighed against cost.

Life is full of tradeoffs.

Anyone who asks for medical care in the hallway deserves what they get.

Little is certain in life, especially when it comes to the future.

If “call” means twelve hours, the term carries fewer negative connotations than when it means seventy-two hours.

Two doctors who talk to each other will consistently give better medical care than one doctor, no matter how brilliant, who doesn’t converse professionally.

Cheese and crackers at leisure taste better than steak bolted.

Contrast is the essence of meaning.

Where there is cultural contact there will be gene flow.  It’s in the nature of young men and women.

Separation anxiety is a universal human emotion.

A toddler, given an object, will find a way to insert that object into an orifice.   

A cut needing stitches raises suspicions of a family under stress.

 People who don’t sleep well get sick.

You can’t know what you can’t know.

Stress and alcohol make things worse which makes drinking under stress a bad idea.

A thin young drunk runs faster than an aging, overweight, well equipped cop in Kevlar, but doesn’t get far because the cop can run in a straight line.

If you’ve seen more than three doctors for the same problem, the chances that I’m going to make you better tonight are not good.

No one can count anything after two drinks, especially not the number of drinks.

Every day I see patients I will see at least one thing I’ve never seen before.

Most lifelong scars are acquired under or near the influence of alcohol, before the age of 10 or between puberty and 25.

Things that seem like a good idea at the time turn out to be a really bad idea when alcohol is included.

High emotions make for high learning.

Every doctor faces information overload; prioritize or be swamped. 

The wonderful parts about day-to-day life lose their wonder when they come every day; but when we go and come back we can relish and savor the ordinary.

The line between work and friends got blurrier and blurrier as the years went on.

Economists have shown that people get happier in proportion to their money only until they’re slightly over the poverty line, then they get more unhappy with every extra dollar.  So don’t buy a lottery ticket, you might win.

More happens in a day of sitting around camp on an island than I care to write or than my audience would care to read.

All work and no play make Jack a dead boy.

Interpersonal respect, hours, money and benefits much be considered as a whole package.

If all the doctors had a sudden attack of sanity and stopped working life-shortening overtime hours, there wouldn’t be enough doctors.

Dead-end and bitterness define each other, and sap the joy from life.

You’ll enjoy the trip a lot more if you’re not in a hurry.

Forty years changes you more than it changes the road.

Chronic pain cannot be controlled in the absence of good, restorative sleep.