Posts Tagged ‘blizzard’

The blizzard to home

March 1, 2017

There’s the net, and we know what we know,

But if something’s uncertain, it’s snow

Is it foolish or bold,                                       

To make a trip in such cold?

Or just plan on making it slow?

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 short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I kept an eye on the internet weather predictions on Thursday preparatory to the drive back to Sioux City, and I could see snow predicted for the evening, but the really hard snow wouldn’t start till after midnight. Bethany and I talked about the trip over lunch.  We decided to try to get as far as we could, and, if necessary, stay the night in a motel in Onawa, about 50 miles from home.  We left in light rain mixed with sleet.  Our neighbors called before we reached Omaha.  The blizzard had engulfed our destination.

We talked it over some more. We decided that even if we could get to Onawa, a closed Interstate at that point would mean full motels.

If we’re going to get stuck, we said, we’d rather get stuck in a town with a variety of good restaurants and an overabundance of rooms.

We dined at the Jaipur, and while we tried a couple of dishes we’d never had before, the snow-covered the car to a depth of 3 inches.

We crept down icy streets to a nearby motel.

We hadn’t even brought a change of clothes, but the front desk had toothbrushes with tiny tubes of toothpaste.

We slept hard and deep and awakened rested to find, after breakfast, the car encrusted with ice and coated with heavy, wet snow. The trunk, frozen shut, required a good deal of coaxing to open.

As I pulled onto the Interstate in Omaha, a car intending to take the same ramp from the other direction spun out while I watched.

Between the two of us, my driving talent lies with traffic, and Bethany’s with snow and mountains. I got us out of Omaha and headed north on I-29.  At the first rest area we changed drivers.

On the way to Sioux City we saw two more spin outs and a half-dozen cars off the road, one on its roof.

The drive took twice as long as usual. But we arrived, safe and grateful.

It snowed and it blew but the cold didn’t approach the negative double digits we’d planned on in Fairbanks. Still it’s all part of the adventure.

 

 

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Meeting the VA’s New Rheumatologist

January 11, 2017

I drove through the snow to Sioux Falls

The place with the old red brick walls

Where it seems it’s the norm

For the staff to be warm

To the vets who walk down those halls.

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 assignments in western Iowa and southeast Alaska, I’m back home. Any identifiable patient information has been included with permission.

I heard this joke in 1982: You walk into the patient’s room in the VA and there are three glasses of orange juice on the bedside table.  What’s the diagnosis?

The punch line goes, “Patient died 3 days ago.”

Fast forward 20 years.  Having suffered for more than 30 years with chronic back pain from ankylosing spondylitis (much like rheumatoid arthritis but affecting the spine) I had started the miracle drug Enbrel a year prior, and finally got an appointment with the Veteran’s Administration rheumatologist in Sioux Falls, South Dakota.

Please do not judge the VA on the delay of care. I separated from the Public Health Service (along with National Oceanographic and Atmospheric Administration, the two uniformed services that no one knows) with such anger that I divested myself of certain papers. After the critical regeneration, booking a first-time rheumatology appointment took the same 6 months that it would in the private sector.

I came unprepared for the warmth and caring that flowed from everyone in the institution. I certainly did not expect two secretaries on their lunch break to help a clearly disoriented vet wandering the hallway, nor to do so with such kindness.

Since then I’ve driven once or twice a year back to Sioux Falls to meet with the rheumatologist. Every month or so I get a refrigerated container in the mail worth about $2,500.

The routine includes a lab appointment; if scheduled for 9:00 I can count on being done with the blood draw by 9:02. I have watched the system acquire bits and pieces of efficiency, until it happens as fast as possible without rushing the patient.

I’ve not had a morning doctor’s appointment previously. The blood test itself takes an hour to run, and I can only imagine the clockwork precision behind the scenes.

I sat down to wait. I napped.  I read a medical journal I’d brought from home.

I chatted with another vet, one of the moral giants who regularly walk the corridors there. I saw a lot of modified heroes.  In the last 15 years I’ve seen the number of women vets steadily increase.

A nurse came out to tell me of the doctor running behind schedule. I told her I understood patient flow, especially in a raging blizzard.

The doctor apologized to me for the delay, too, before anything else. I’d not met her before.  Young, energetic, and kind, she has a quiet competence about her along with the extraordinary intelligence that  permeates the subspecialty.

We both spoke well of the rheumatologist who preceded her during his semi-retirement, and I thanked her for coming to the VA. We agreed that telemedicine might be the future in a few specialties, but not in rheumatology.

Not until I explained my ankle problem in medicalese did she ask, and I told, of my status as a physician.  After that things went much faster.

I spoke briefly of how much I liked locum tenens. But I didn’t give details, so as not to make the next patient wait longer.

Where I’d walked into the building in low visibility, I walked out in bright sunshine. A fierce north wind which ruined gas mileage on the trip up sped me on my way home.

 

A blizzard? Maybe not such bad luck.

December 16, 2015

It’s winter, and wouldn’t you know
It’s time for the wind and the snow
With the luck of a wizard
We had us a blizzard
And I handled it just like a pro.

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 the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Right now I’m in western Nebraska. Any patient information has been included with permission.

I broke a tooth chewing on a slice of dried mango, and asked around the hospital for the name of a dentist. Good luck brought a 7:30AM appointment next day, bad luck brought a blizzard that night.
I started early next morning but cleaning the car and creeping down the ice-covered highway with low visibility took time.
I don’t mind going outside in the cold. Last winter, in Nome, Alaska, I cheerfully walked a kilometer to and from work. I frequently walked in the ditch, to get away from traffic, and when I finished that part of the walk, I climbed out.
But I mind going into a ditch if I’m in a car.
Still I attended to my hospital patient before dawn, put in orders, put off writing the note, and went out into the snow.
The temp had warmed up so that two inches of fat, wet flakes covered the car in a half hour. I brushed and scraped the car again, and crept down the hill into town.
In this sparsely populated area of the country, the dentist has a lot of out-of-town patients, and he faced a schedule full of cancellations. If I could get the prep work for the crown done that morning, it would cut my time away from clinic, and would help fill his schedule.
We saw it as a win-win situation.
I dozed in a state-of-the-art dental suite while he drilled and lasered, and walked out an hour later with a temporary crown to find 4 inches of fat, wet flakes covering the car. The white stuff came down so fast that it covered the armrest inside the door in the short time it took to put the brush in and seat myself.
Patient flow slowed to a crawl in the clinic.
I discharged my inpatient before lunch, and learned I could get free chili or chicken noodle soup in the cafeteria.
The cafeteria here doesn’t sell hot food to employees, but has a bank of 5 vending machines with a microwave, and the offer of hot soup came as a pleasant surprise.
I took care of a total 3 patients in the morning session and 3 patients in the afternoon session. My access to the EMR, NextGen, came through, and I have started the odious task of mouse clicking. I remained thankful to the blizzard that I didn’t have more time pressure while on the steepest, lowest point of the learning curve.
We closed early, at 4:00PM. I went outside to clean the car off, but the wind had picked up and the temperature dropped, so it went easier than the three times before. Visibility improved, and I arrived back at the townhome ahead of schedule.
I would have preferred a commute short enough to walk, but I benefited from very good dental services. I would have preferred better weather, but I got the work done in a timely fashion without cutting into my schedule.
Maybe the blizzard wasn’t bad luck after all.
Life is full of tradeoffs.

Highlights of six weeks in Barrow

March 1, 2011

You might say it flew far like a sparrow

Or fast and straight like an arrow.

     But either way time

     Like a vacation sublime

Went fast while we were in Barrow

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I just finished an assignment at the hospital in Barrow, Alaska, the northernmost point in the United States, and I’m in Anchorage for two days.

Six weeks in Barrow, Alaska, has flown by.  We arrived at the end of the two-month Arctic night.  We went out in -75 degree F temperatures, and we stayed inside while the worst blizzard in four years raged outside.

Gone!

Blizzard in Barrow

I worked 360 hours while here, but the other doctors worked more hours than I did.  I received the lightest load on the call schedule.  I didn’t work any nights.

I saw a lot of broken ankles, from snow machine accidents and falls on the ice.  I picked up two cases of vitamin B12 deficiency, nine cases of vitamin D deficiency, two cases of hypothyroidism, and not one case of frostbite. 

I took care of people from all over Alaska, including Barrow.  I also saw those from Tonga, the Philippines, Hawaii, Korea, California, Tennessee, Kentucky, Mexico, Canada, Puerto Rico, Florida, England, South Africa, Colombia, and Ireland.

I met people who had survived plane crashes and gunshot wounds.  I made personal acquaintance with more than a dozen whaling captains, and more than two dozen who had personally killed whales.

A lot of the men had taken polar bears, most at close range with low-powered rifles, many in self-defense.  One had killed a polar bear without a firearm at all.  

I talked to women who sew the seal skins onto umiak frames, and the men who hunted the seals.

When a white-out shut the town down for four days, I suited up and went outside.  Twenty paces from the building I thought better of the venture and turned back.

I didn't have to go out in a blizzard to ice up.

We watched the first dawn after sixty-three days of darkness on the afternoon of January 24, and watched it set less than two hours later.

First sunset and first sunrise in 63 days, at the point. January 23 2011

The medical community viewed the Superbowl in the Commons room, farther north than any other medical staff activity in the country.

I talked to other hunters who shot caribou, wolf, goose, duck, wolverine, seal, and walrus.  Several people had been hunted by polar bears, but lived.

We saw the Northern Lights, I for the first time and Bethany for the second.

We attended Kiviuk, the Messenger Feast that happens every two years.  I saw dancers passionately portray heroic stories with their dances.

Afterwards, while the Northern Lights swept mutely across the sky, we watched the best fireworks display I’ve seen.

While we were here we saw pressure ridges form in the ice on the Arctic Ocean.

For every active drunk I took care of I met two in recovery.

Bethany taught sign, Inupiak, Special Ed, third grade and fifth grade.  She made a lot of new friends, one of whom she started into knitting.  She got a lot of exercise.

I drove twice, a total of less than fifteen miles.

We had the best Kung Pao chicken and Mongolian beef we’ve ever had.

Both of us lost a few pounds.

Warming temperatures and gale-force winds

February 25, 2011

We stepped out into the storm,

Which didn’t quite come up to norm

     Just below freezing

    The contrast was pleasing

The wind seemed ever so warm

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

As I write, the wind howls outside and the building shakes with the gusts.  The windows don’t rattle because in a climate as unforgiving as Barrow’s windows have to fit tightly.

Last night Bethany and I walked to the store in the long arctic twilight.  The blizzard had lightened, the wind had let off to 30 mph (50 kph), and the temperature had risen to a record high of 29F (-2C).  As soon as we stepped out the door, we felt weird.  Six weeks of subzero cold has not kept us inside, we’ve adapted to Arctic winter temperatures with clothing and physiology.  The warmer air felt strange on our faces, and the dull crunch under our boots came alien to our ears, accustomed to the squeak of much colder snow. 

I made a snow ball.

When we stepped out of the lee off the building the wind caught us full in the face, and I pulled my hood up.  Immediately the rush of air caught inside my hood and flooded the inside of my parka.  I welcomed the ventilation because I had started to overheat. 

By the time we’d crossed the lagoon and turned north the wind came at our backs, pushing us along.

We slogged through most drifts, but when we crossed the road by the post office Bethany sank in up to her waist. 

Further on we turned into the wind but it didn’t sting our faces.  Winter, though deep, chilly, and dark, has flown by, and the relative warmth carried the promise of spring. 

Warmer snow melts quickly and, ironically, cools the face faster than very cold snow. 

Inside the store, our coats, hats, and mittens filled the grocery cart.  We ignored the shocking prices and bought bread, eggs, fruit and dessert.  In the checkout line I observed, to Bethany, the contrast between an orchid print of a woman’s parka and the wolf fur on the hood’s ruff. 

The wind blew full in our faces on the trip home.  Darkness closed in, and the dramatic pink and gray of the sky faded into night.  Half-way back I took over carrying the pack.  Where the gale swept the snow from the levee we trod on ground and ice frozen hard to the consistency of stone.

Inside again I observed to Bethany that dry, cold snow doesn’t clump on your boots or cake in your fur ruff like the wet snow of the day, just like the stuff we’re used to at home.

Polar bears and rumors of polar bears

February 24, 2011

We had a bit of a scare

When the rumors all said “polar bear”

   Such a big predator

   Right outside of our door

You can go out unarmed if you dare.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

During the blizzard our patient flow fell yesterday.  This morning at our daily morning conference, we had few patients to discuss.

Not many made it in yesterday, among them a disproportionate number of drug seekers.  We talked about that problem at length.  Despite our frustration we kept good senses of humor.  Two topics generated most of the rest of the conversation, one was the weather with blizzard conditions again forecast starting at noon.

We also talked about the polar bears.

Barrow sits on a peninsula that juts into the Arctic Ocean.  With 7500 souls in towns, the bears have an area the size of Wyoming to roam and never see a human.  Natives legally hunt and eat bears, and the bears sometimes hunt and eat people.  The Barrow Inuit have drawn most of the bears away from town with a designated whale carcass dump site, six miles from any human activity.  Still, bears go where they will, and last night three of the white bruins came into town.

Bears are a fact of life in Alaska, an undeniable reality.  There are many places where getting out of a vehicle unarmed is just plain stupid.

Thus, less than twenty-four hours after our arrival, we had a pamphlet slipped under our door.

Polar bear pamphlet found under our door

 

Last night, while Bethany and I sat in the Commons, a nurse called to us from the hallway to come see the polar bear that had been sighted on the lagoon.  We jogged through the corridors to our apartments, and watched the tail lights of eight snowmobiles and trucks running patterns on the ice outside the hospital housing.

The large white carnivores had prowled around the elementary school, we heard, and had last been seen where we were looking.

Bethany, who had walked to the elementary school in the dark that morning, and had almost walked back but for the blizzard in the afternoon, said that she was even happier she’d accepted a ride. 

I learned that the bear police had been called out.

“Bear police?” I asked.  “There is such a thing or are you pulling my leg?”

The bear police get called out any time a bear is sighted in town.  The first one to kill the bear gets to keep it.

Snow machines motored, eerily quiet, on the ice in front of the windows we were looking through.   I didn’t see a long gun on the sleds or riders.

This morning, we heard three bears had been seen, one by the school, and two on the lagoon.

We found this sign posted at the exits:

Just read the sign and ignore the spelling.

Probably something I’ll never see in Sioux City.

When Bethany and I walked to the grocery store this evening, we debated borrowing a firearm for the walk.

A blizzard shuts down the hospital

February 23, 2011

Was ever a walker so bold

As to go out into the cold

     Only a wizard

     Could get through this blizzard

And the hospital got put onto hold.

 

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

 

The author, outside in a whiteout

 

Winds howled around the hospital loud enough last night to interfere with slumber.  My Care Initiatives Hospice meeting took place behind schedule because I had overslept.  Skype failed to pick up the nuances of blizzard sounds while we talked.

Bethany walked to her job at the school, about two kilometers away. 

“You’re sure you want to do that?” I asked.

“I’ve got my phone,” she said.  “Worst comes to worst I’ll call a cab.”

Taxis are part of Barrow.  They are quick and cheap.

After she left I started trying to use my cell phone and found I had no service, and no way to call her.

At morning conference we talked about the weather and how it makes medicine in Barrow unique; we can’t do what we can’t do and we don’t have what we don’t have.  For a complex litany of reasons we’ll not be able to do transfusions outside of absolute life-and-death situations until a plane can land with certain vital supplies.

Planes won’t be able to land until the forty mph winds die down.

Bethany called.  She had gotten to school safely, arriving at 730.  Promptly at 735 the administration closed school.  Nonetheless, she said, she had work till 230.  When I rang off I recounted her morning’s exploits; she drew a round of applause.

Though we discuss matters of vast importance, though we may disagree about things, the mood of the meeting stays lighthearted. 

At the Clinic Formerly Known As Mine, we called snow “patient repellant.”  We never got mad at those who didn’t come in during bad weather, we looked forward to a more relaxed schedule.  With a blizzard raging, only one of my scheduled patients showed up.

I used the time to phone other patients about lab work.

Lunch passed leisurely; the snowstorm occupied the conversation.  I learned (in Spanish) that the current storm won’t break for three days.

After lunch, two patients showed despite KBRW’s announcement that the hospital had closed.  Most of us just stood around and chatted.

Bethany called; with school closed she’d gotten a ride to within three blocks.  Safe and warm inside an apartment house, she was considering walking home.  I told her to stay put or get a ride.

Two nurses came in, looking cold, wet, and frightened.  They left early, their truck stuck fast in a drift, and they’d had to call 911.  In the process of walking from the truck to the police they’d gotten wet.  One, on the verge of tears, started to shiver.   I put her on the phone to Bethany as a warning to not try to brave the elements. 

We cut the conversation short when we recognized hypothermia.  As we swarmed around her with towels and warmed blankets, the hospital PA system announced all those not living on hospital grounds needed to report immediately to Medical Staff Administration.  Those employees will form up into a caravan to make sure everyone arrives home safely, even if their vehicles don’t.

 I took these pictures from our apartment window:

Visibility going once...

 

Visibility going twice...

 

Gone!

And…Gone!

Even doctors have to wait to see the doctor

January 10, 2011

I don’t have a diagnosis or why,

As the tears run out of my eye.

     It’s just the creation

     Of a foreign body sensation

I’m really not one to cry.

I went to the Clinic Formerly Known As Mine as a patient today.  Despite a steady snowfall on top of six inches accumulation from yesterday, I went out into the cold, with the mercury here in Iowa reading two degrees colder than in Barrow, Alaska.

Two days ago my left eye started feeling scratchy, and I woke in the middle of the night to put in Celluvisc eye drops, which have worked well in the past.  They helped for a short time, then the sensation that I had a boulder stuck between my upper lid and my eyeball increased until, I was sure, the Rock of Gibraltar had taken up new residence.

I don’t mind waiting for my doctor.  In years past I have found a few minutes of peace and the chance to read a magazine in physician’s waiting rooms.  But today I sought relief from major, immediate physical discomfort.

During her examination the numbing drops from my doctor came as a wonderful relief, which I knew would only last twenty minutes.  The flourescein drops showed a small corneal abrasion.  My doctor inverted my upper lid but found nothing stuck there.

On the way out I received many hugs and questions about my upcoming plans.  I hope all patients are treated so warmly, especially on so cold a winter’s day.

You can’t call it a blizzard unless wind combines with cold and snow, but the white stuff has continued to fall for a day and a half and slippery doesn’t even come close to describing the roads.

On a day when going to the doctor carries significant risk, I drove to the drug store, fearing its closure.

I bought my prescriptions, and I also bought more Celluvisc.

I first made my acquaintance with this very soothing eye drop twenty-five years ago, and have recommended it frequently since.  If the problem went away in less than twenty-four hours with Celluvisc, it did not warrant a visit to the doctor. 

I broke open one of the single use units in the car before I drove away from the pharmacy, dropping the soothing artificial tears into my eye.  I waited to get home before using the antibiotic and the anti-inflammatory.

Continuing pain demanded more Celluvisc, a couple of Tylenol, and recumbent position with my eyes closed.  Two hours later, I called my friend, the ophthalmologist.  Two hours after that, he has not called me back yet. 

Just as well, most of the pain has gone.

Even doctors have to wait to see the doctor.

Application of medical first principles on a Tuesday in Keosauqua

December 21, 2010

Why do doctors go gray?

Is it all work and no play?

     Life can be a ball,

     Though you’re working on call,

Just don’t give in to dismay.

When I’m on call, nights or weekends, I get a lot of calls from people who have self-diagnosed an antibiotic deficiency and want a prescription called in.  Pain with urination, sore throat, and cough comprise the most frequent complaints.

I would like to say I don’t ever yield to the request, but on rare occasions I do.  I weigh the risk to the patient of treatment with an exam versus the risk of treatment without an exam.  Most of the time I’m pretty rigid, but flexibility sets in during extreme weather.  Last year a blizzard descended on Sioux City when I had Christmas weekend on call.  On a day when it took three hours to get from my garage to the street, I said “Yes” a lot.

Most sore throats do not benefit from penicillin.  Most pain with urination is not urinary tract infection.  Most earaches do not come from ear infections.

Today I saw four patients with painful urination, abrupt onset, accompanied by blood in the urine.  One had a urine infection.

I work very little to write out a prescription for three days of antibiotics; I work a great deal more explaining why the patient shouldn’t take antibiotics.

Of the last nine patients with pain in the ear, one had an actual ear infection.

Three other patients, all smokers with emphysema, came in short of breath today; they all left with prescriptions for antibiotics and inhalers.  One got a prescription for prednisone (a steroid).

On six occasions today I added up the costs of peoples’ bad habits.  “OK,” I’d say, “How much are you paying a pack for Marlboros/a bottle for Mountain Dew/a cup of coffee/a pack of generics/a case of beer?”  I got out my calculator and said, “Dang!  Eight hundred dollars/twelve hundred dollars/nine thousand dollars a year!  They must pay you well!  I’m a doctor and I couldn’t afford that.”

People who work with livestock in general and horses in particular don’t complain much, and if they do, I’d better listen.  I applied that principle twice today.

Three folks with mental health histories were in today; their complex medical problems took time.  I considered the principle that craziness doesn’t protect from physical illness.  I have a lot of lab results pending.

Four patients let drop the fact that a close relative had died in the last six months.  I listened and I sympathized.  I remembered the ten months after my mother died, when penicillin injections kept me going during a succession of eleven culture-proven strep throats.

Depressed patients get sick, and sick patients get depressed.

Blizzards, syphilis, and nosology (the study of how we know what we know)

December 12, 2010

How do we know what we know?

If the test says ‘yes’, is it so?

     False positive rates

     In some disease states

Can lead to some terrible woe.

 

Cold came to Iowa overnight, strong enough to generate national news.

I arrived to make hospital rounds yesterday, and talked with the doc on call.  We eyed the weather reports and I took over call early, allowing the other physician to get home before a blizzard hit.

Patients like to stay sheltered when the wind chill goes to double negative digits, only the much sicker come in. The forecast called for 40-50 mile per hour winds, heavy snow, and temps around zero.  After supper I packed an overnight bag and returned the half-mile to the hospital.      

I didn’t have to stay the night at the hospital; I could have waited to get called.  I wasn’t sure the blizzard would really happen, but I didn’t want to face whiteout conditions trying to get to the ER. 

I drifted to the nurses’ station first.  With a census of three, the staff outnumbered the patients.  We chatted about the cold, deer season, and the patients.  I got some surprise lab results.

Mostly we get information from laboratory tests to confirm what we think is wrong; rarely (not never) do we generate as much decision making from x-rays or blood and urine tests as we do from talking to the patient.  Sometimes the patient can’t talk, can’t remember, or won’t tell the truth.  In those cases lab and x-ray add heavily to the diagnosis.

Yes, I ask for tests “just to make sure,” and sometimes when the case perplexes me I’ll order a large number of lab tests.  Ninety percent of those results come back as expected.  Ten percent of the time they don’t.

I finished residency thirty-two years ago, when syphilis used to be called the ‘Great Pretender’ because it could mimic any other disease.  As med students we learned to order certain labs as a matter of course, especially the serologic test for syphilis, aka STS, Wasserman test, VDRL, or RPR.  Later we learned to order the confirmatory test, the free treponemal antigen (FTA) or Treponema palladium plasma antigen (TPPA). 

As rates of syphilis fell, the disease changed and enthusiasm for testing waned.  In medical school, we were taught that the infection always started with a sore.  By 1990 the sore happened occasionally.  Now we almost never find one.

I still test for syphilis despite low rates.  Since 1982 on five occasions the test came back positive and surprised us all; on one occasion, years ago in another place, the positive result startled me but not the patient.  I came away with a history lesson in riverboats and an appreciation for Midwestern life in the thirties. 

The diagnosis remains a problem in nosology.  The first test has false positives (as in Lyme disease) and false negatives (late in the illness), the second test has no false positives but cannot distinguish active disease from prior infection.  In the end, there is no substitute for clinical judgement.