Posts Tagged ‘cough’

Measles, a word the 7-year-olds haven’t heard

April 9, 2017

Here’s a contagious word to the wise

If there’s rash and runny eyes

With a cough, I suppose

Look! How runny the nose!

And it’s MEASLES! The CDC cries!

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.

About 3 weeks ago I received an email from the Iowa Department of Public Health about a case of measles. The person (age and gender not given) had been in the Omaha airport on March 12.  Diagnosis of measles had come on March 15, after visiting 3 different healthcare facilities.

So I was on the lookout for a disease I hadn’t seen for 30 years.

Finishing my Indian Health Service contract in 1987 at the Tuba City, Arizona Indian Health Service Hospital, I saw hundreds of cases, and I had to learn about the disease. Measles discussions center on the 3 c’s: cough, conjunctivitis (runny eyes), and coryza (runny nose); the patient looks sick, and has a fever.  The rash starts on the face, and in the next three days works down the body, concentrating in the midline, armpits, and groin.  The 3-day or German measles has a similar looking rash that also starts on the face and spreads down, but people don’t get nearly as sick.

At the time, that reservation had an immunization rate close to 100%, but when the dust settled, the case count came very close to a 5% vaccine failure rate. Since then, the MMR has gone to a two-dose immunization schedule.

With the alert fresh in my mind, I had reason to think of the things I learned and saw so many decades ago. Working a game of incomplete and imperfect information, I called the state Department of Health.  Connecting eventually with an expert who had never seen the disease, but knew what to order, I heard for the first time of a viral transport medium called M4.  And I learned to use a culturette or a Dacron swan, not cotton and certainly not wood.

We still have no treatment for the disease. And with the illness almost extinct, we probably won’t invent one.  Yet measles still runs into complications in almost 10% of those who have it.

Exposure confers lifelong immunity, and only humans can get measles. Thus as an undergrad in anthropology, in one class we did calculations based on 2 week contagion, 3 week incubation, and generation length of 20 years to figure out how what size population can support the disease.  We decided, eventually, that measles couldn’t be more than 50,000 years old.

Measles remains contagious in the air for 2 hours after a person with an active infection leaves a closed room. Thus the case that triggered the alert, arriving on an airplane, exposed a lot of people.

I want to know about that case. What irony or drama surrounds the circumstances of inadequate vaccination?  Who did the exposing, and how sick did that patient get?  Where was the exposure, and was it linked to the Disneyland outbreak?

I never had measles as a child. The son of a physician, I served as a test patient when I was 14 for the first measles vaccine that only served to deplete what my meager natural immunity.  I had to wait till middle age to get an effective vaccine.

Later that day I asked a 7 year old if he’d ever heard the word, measles. “No,” he said, “What are they?”

The antivax movement makes no sense. Mercury has been removed from the vaccine, and all the evidence linking MMR to autism was fabricated by one researcher who has since owned up to his deception, yet that myth persists.

I fear that the antivaxxers may get enough traction to let the genie back out of the bottle, and that the word, measles, may once again become part of the language.

Admit ignorance: practice it, get good at it.

March 13, 2017

If you don’t know a yes from a no,

And if you can’t tell the fast from the slow

Listen up, please,

For I can do it with ease,

Just say out loud, “I don’t know.”

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.

Over the weekend I observed the anniversary of my graduation from medical school. I remember the night well; I went out to the Chinese restaurant in East Lansing (at that time, there was one) with my father and my brother.  My fortune cookie said, “You will have great power over women.  Use it wisely.”

Before and after I have heard many commencement speakers, but the only one I remember was the one from March 11, 1979. “When you get up in the morning,” he said, “First thing, look in the mirror and say, ‘I don’t know.’  Practice it.  Get good at it.”  I remember a good deal more of that speech, but that particular commandment came to my mind this morning.

The patient came in for follow-up of cough. He had had all the right treatments before he got to me, but he wasn’t getting better.  I repeated the chest x-ray and didn’t see pneumonia.  Antibiotics, steroids, breathing treatments helped but not nearly enough, and he felt worn out from the cough bothering his sleep.  I said, “I don’t know what’s wrong, but, clearly, something is wrong.  And I know exactly what to do when I don’t know what to do, and that’s to send you to someone who knows more than I do.  Because I’m the world’s final authority on nothing.”  We were lucky to get him a follow-up appointment with the pulmonologist in a week.

But at the end of the visit I told him about my medical school commencement speaker, and how good I’d gotten at saying, “I don’t know.” And then I asked permission to write about him in my blog.  “I won’t say name of course, or age, or gender, but…”

“Doc,” he said, “You can tell ‘em my name is ### and I’m ## years old and I’m ### for all I care. Especially if it’ll teach other doctors to admit when they don’t know.”

I can hope.

An awful lot has changed in medicine since 1979. We don’t use penicillin for pneumonia any more, and rarely do we bring out the digitalis.  But doctors still have to admit when they don’t know.  It’s one of the rules of the game.



The doctor takes the wrong end of the scalpel

March 4, 2013

In the head there’s this thing called a brain.

Where we feel our pride and our pain

But when the cutting is done

Are narcotics just fun?

Or the source of some ill-gotten gain?

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.

Recovering from surgery cuts into the desire to write, but I’m doing better now.

Even doctors must have doctors; the internal dialogue that leads us to minimize contact with our own profession has gradually led us to healthier life styles.  Few doctors smoke in the 21st century; most of us exercise regularly.  While no doctor should prescribe for him or herself, neither should any patient completely abrogate self-advocacy nor decision-making. 

I won’t dwell on the circumstances that led me to a repeat surgery; denial worked for a long time but eventually failed.  Thus on Valentine’s Day I sat in our local specialized surgical center, hungry and thirsty waiting for anesthesia.

The procedure started on time, but went long, only because of the nature of the problem.

A lightweight when it comes to most medications, I dozed off and on for the rest of the day.  When it came time to leave, I adamantly refused a prescription for a popular narcotic.  The exchange with the nurse went several rounds and finished with her tearing the slip to bits and putting it in a small plastic envelope designated for that purpose.

All narcotics slow the gut and suppress the cough reflex.  I feared constipation (after a major abdominal procedure) and pneumonia more than I feared pain.   Nor would my marginal kidney function permit me the usual pain relief of the NSAIDs (a drug class that includes Ibuprofen, Alleve, Toradol, diclofenac, and 28 others).

Which left humble acetaminophen, also known as Tylenol.

If we assign post-operative pain a range of 1 to 10, we know that the much-abused oral opiates like Percodan and Norco can bring the pain down by 2.7 points in the same study where an inactive pill will bring it down by 2 points and Tylenol by 2.1 points.

(Interestingly, propoxyphene, the active ingredient in Darvon, now removed from the market, would decrease it by 1.7, which means that despite bringing euphoria, a drug could aggravate acute pain; a phenomenon we see with marijuana and chronic pain.)

I have spent most of the last 5 days asleep, but today I’m coming around.  My appetite and my sense of humor have palpably improved through the day.  I still fear coughing but I do it anyway. 

I didn’t actually need the narcotics.

When I talk to my non-drug abusing patients after a surgery, most of them didn’t, either.

Fever, cough, aches, and plunging temperatures when the sun comes out

January 27, 2011


Epidemics of this are not new

But what is a doctor to do?

    With coughing and aches

    Till the high fever breaks,

The typical symptoms of flu.

Synopsis: I’m a family practitioner from Sioux City, Iowa.  I’m taking a sabbatical to come back from the brink of burnout.  While my one-year non-compete clause ticks off, I’m having adventures, working in out-of-the-way places, and visiting family and friends.  Currently I’m on assignment in Barrow, Alaska, the northernmost point in the US.

Three symptoms distinguish real influenza: fever, cough, and aching.  Each year the particular circulating strain will show some unique characteristics; last year, for the first time, vomiting and diarrhea accompanied most cases.  Some years headache happens to most of the patients, other years people complain of profusely runny nose.

Chaos mathematicians and complex systems analysts can explain why the flu in a community will reach a tipping point and go, well, viral.  We’re all familiar with the scenario; a few people get the flu, the first cases aren’t too bad; later cases get much worse.  At the peak of the epidemic, our co-workers stay out sick, the schools close, and we can’t get anything done.  Ninety percent of the cases occur within three weeks; the epidemic starts in the north and spreads south.

The scenario repeats itself yearly.  Except for last year, when the pandemic H1N1 “swine flu” turned out to be more of a sardine than a shark, most people got their flu shots and flu season went well.

Many years the tsunami of the flu season overwhelms the medical infrastructure; in 1993, at the end of the season, neither love nor money could have bought an influenza test kit, amantidine nor rimantidine and the chronically ill died by the score.

The virus has Barrow in its grip this week; more than half the patients I’ve seen in the last week were suffering with the same symptoms.  Today we received confirmation of influenza.

With housing in short supply in Barrow, people crowd.  Contagious diseases, especially those spread via the respiratory route, run rampant in these conditions. 

I’ve been working late every day; today I hit forty hours and went into overtime.  Yesterday I finished before supper for the first time since I got here.

I labor with some very good doctors, all hard-working team players.  We have a well-equipped hospital and a well-stocked pharmacy, and exactly six exam rooms.  Emergency medical transports, dramatic life and death cases, leave by air daily.

I wish I had more time to listen to each patient’s story.  I want to ask questions like, what did you find when you got there?  How many geese did you get and how did you get that many?  How can you load eight caribou to be pulled by one snow machine?  How do you find a wolverine?   What is the best way to use fur as a ruff on a parka?

Outside the temperature runs twenty-five degrees below zero till the sun comes up, and in the clear skies of the afternoon the mercury plunges and the radio warns people not to go out.

A walk to the grocery store at thirty-five below

January 20, 2011

We walked in the snow and the ice,

The moonlight was ever so nice,

     Ignore all the clocks,

     Watch out for the fox

Who goes out eating lemmings and mice.

The intense arctic cold doesn’t stop Bethany and me from going outside.  Under a full moon, with clear skies, we walked out to the airport last night; the wind chill dropped the effective temperature to -35 degrees Fahrenheit.   My breath condensed on the faux fur ruff of my parka as well as my beard, which led to our evening discussion of hoods trimmed in fur.

Hunters eagerly seek the wolverine here, but I also see wolf, beaver, lynx, otter, arctic fox, grey fox, and red fox on outer wear.  Tanning skins taken locally falls to the women and the women get the best of the furs; men, for the most part, get the trimmings. 

Most arctic fox in this area carry rabies.

Snow crunches at high frequency in this weather.  Barrow receives little precipitation, less than five inches per year on average, so when snow falls the wind blows the ground bare between snow drifts.  Nonetheless moonlight here on a clear night comes in with a “very bright” rating.

The afternoon clinic ran busy and ran late; I worked through the dinner hour and finished fatigued.  Both yesterday and today I took care of four people in one family in one room.

The outpatient area of Samuel Simmonds Memorial Hospital has six exam rooms and an ER with two bays.  The first patient of the afternoon was quite ill and needed a good deal of medical care, staying in the department for three hours.  Patients who signed in at 4:30 didn’t get seen till after seven.

Most patients today had cough with or without fever; the circulating syndrome apparently started on Friday, and the virus has gone ripping through town.  As usual, those sickest before the epidemic  suffer more during the epidemic.

I find great pleasure in the side conversations I have with the hunters here.  I can pick out whalers most of the time by the glow on their faces.

Two days ago Bethany and I walked to the store.  It wouldn’t rate as an adventure if it hadn’t happened with -45 degree wind chills, and a full moon that didn’t set.  Our glasses grew layers of ice, as the wind whipped wisps of snow along the ground.  We found good traction on the hard dirt roads that have been snow-packed by vehicles but textured by machine.

The grocery store ranks as a medium-sized supermarket.  The ammunition section comes well stocked with common calibers like .223, .45 ACP and 7.62×39.  The presence of a good selection of .22 Hornet surprised me.

The fact of nectarines from Chile in the produce section at $4.50 a pound astounded me.  I can remember saying my mother saying that a hundred years ago kings couldn’t get what can be commonly found in a grocery store; stone fruit in the middle of winter ranks as a triumph of modern man.  I said, “Bethany, I’m buying some.  Contrast is the essence of meaning.”

Thirty-eight CT scans later, life’s lessons from a musician and a teacher

January 6, 2011

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog. 

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant. 

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her. 

“Well,” I said, “Just lay back on the exam table while I check your tummy.” 

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart. 

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.   

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.

Of chest pain and delusional GPS units

October 30, 2010

The chest pain is the worst part

Though a work-up was done at the start

     I’m out here in rural

     So I got a referral.

The problem, I think, is the heart.

I call my GPS unit Sweetheart.  Most of the time she (she speaks with a feminine voice) reliably gets me from place to place. 

Once in a while she loses contact with reality; while Bethany and I were driving from Anchorage to Fairbanks, north of Denali she became quite confused and wanted us to turn left when all we could see was roadless moose, bear, and wolf habitat.

I drive 1.3 miles from my hotel to the clinic where I work, and most of the time Sweetheart guides me correctly.  About one-third of the time, in one particular segment of the drive coming or going, she gets confused and tries to have me do maneuvers ranging from U-turn to cloverleaf.   I’ll usually say something like, “Are you sure, Sweetheart?  Did you take your medicine today?”  I’ve now learned the route, and the places where she becomes delusional, and I’ve taken to not turning her on to get to work.

Friday afternoon I took care of a third grader, whose mother gave me permission to include the information below.  With a main complaint of cough, he has a long history of chest pain and pallor with exertion.  Sometimes if he plays too hard he has to stop and rest.  His cough started with one of those episodes.

The mother read the alarm on my face, assured me the patient had been to a pediatric cardiologist, and described a thorough work-up.

The mother and I agreed in our lack of comfort with the situation and the desirability of a second opinion.   I called one of my colleagues and friends, a pediatric cardiologist in Sioux City.  I gave him the story and he accepted the referral.  Then I told him why he hadn’t heard from me since May, what I’d been doing and where I’d been going.  I explained that my non-compete clause doesn’t apply thirty miles away from Sioux City.

After we hung up I gave the mother the doctor’s name and phone number so that she can call and schedule an appointment.

Then I did yoyo tricks for the patient.

No doctor practices in a vacuum, all of us depend on a referral network; I’m most comfortable sending patients to doctors I know and trust.  In this case, I didn’t know the pediatric cardiologist the patient had seen, but I knew the history sounded like a heart problem.

There is no substitute for thinking things through.  No matter how good your GPS unit, you still need to watch where you’re going.

The worst part about giving free advice is that it’s not taken, even when it’s asked for.

September 7, 2010

This evening I went to the store

I won’t call the person a boor

    Nor would I scoff

    At the problem of cough,

I smiled and walked out the door.

I walked into a grocery store this evening, looking for the weekly circular, hoping the competition would match a very good price on prime rib, as Bethany had found them out of stock earlier in the day.

The circulars were not to be had. 

Sioux City is a small town by US standards.  I can’t go anywhere without running into people I know and former patients.  In the short time I went from the automatic IN door to the OUT door, a person stopped me.  I will not disclose age, gender, or other identifying data because of confidentiality. 

Actually, I recognized the person as a former patient and waved; the person hailed me and bid me come closer.

“You used to be a doctor, right?”  the former patient asked.

“Sort of,” I said.  The whole truth, including locum tenens, non-compete clause, changing practices, and wanting to slow down so I didn’t burn out, would have taken too long and would have been outside the person’s understanding.   Nor would the former patient have comprehended the word sabbatical. 

The existential question of being a doctor was left completely alone, the person wouldn’t have understood that few who have been through med school and a year of internship can ever stop being a doctor, much like Marines never get over being Marines.

I shook hands and started to move away. 

“How come I’ve got this cough right here?”  The person aimed an index finger at the throat, two inches below the voice box.

“I’m taking a year off,” I said.  “I’ll probably back in practice next June.”

“Same place?” the ex-patient asked.

“No, someplace else.”

I forcibly extracted my hand, and smiling, quickly backed out.

Many people value their privacy, and I hear a lot of docs grouse about such encounters. 

I don’t mind them.  It’s part of who I am and it reflects my place in society, it’s a good place and I enjoy knowing it.  My father, a cardiologist, never had an unlisted number, neither have I.  In the thirty-one years since I graduated medical school exactly one patient abused the listing.

I don’t mind people asking me for free advice; I resent it when I give my best counsel and it isn’t taken. 

So when people walk up to me at a party and say, “Doc, I was wanting to know if you’d give me some free advice,” I say, “If you follow my recommendations, the advice is free.  If you don’t do what I say, I want you to send me a check for $75.”

 No one has sent me a check so far, but I don’t delude myself

Adverse Drug Reactions and Other Delights

July 2, 2010

For problems that tend to persist

Take a look at what’s on the drug list

     Symptoms varied and strange;

     A small patch of the mange?

Find a drug we can stop, I insist.

I enjoy making people feel better.  Finding the problem and improving the patient before they leave brings a wonderful feeling.  Occasionally I get a doctor’s moment, when my strengths come together, I ask the right questions, and heal with words; it doesn’t happen often.

Every year or two I cure a man’s headache by moving the wallet to a front pocket.  Once or twice a year I fix a woman’s headache by reducing the load in her purse; more often by getting her to either loosen her hairstyle or cut a couple of feet off her hair.

I really enjoy watching people get better when I stop drugs rather than starting them.

The three top drugs I love to hate are nicotine, alcohol, and caffeine, in that order.  True, I get more than half my business from them, but I’m at a phase in my career when I want to slow down anyway.

The top prescription drugs I love to stop are the statins, like Lipitor, Crestor, and Pravachol and others.  If a person comes in with otherwise inexplicable bone, joint, or muscle pain, I judiciously ask them to stop the statin (if they’re on one) and come back in a week or two.  More than half the time the pain is gone and the patient is grinning.  Then I start the hard process of getting the cholesterol under control either with a statin plus coenzyme Q 10, or by turning to other agents.

Many a patient came in with a dry, hacky cough and no other symptoms, and asks if it might be the lisinopril (or other angiotensin converting enzyme= ACE inhibitor) prescribed for high blood pressure.  Of course it could be, I said.  In fact, it probably is, so stop that drug (the entire class can give such a cough) and start this other drug, an angiotensin receptor blocker, or ARB.  And come back in a week or two and we’ll see how you’re doing.  The shift from an ACE to an ARB is pretty straightforward.

If a person takes a drug and the drug is distributed throughout the body, one would think that an allergic skin reaction would be throughout the body’s covering.  Very difficult to diagnose is the fixed drug eruption, where a small part of the body, less than six square inches, reacts to a medication; it is well described in the medical literature.

There are at least two case reports of people who had a rash in reaction to tap water.  Now if a person can have a rash in response to water, then any person can have any reaction to any drug. 

Thus we get to one of my governing first principles, ABCD: Always Blame the Cottonpickin’ Drug.

Sick and missing Nalukataaq.

July 1, 2010


Three weeks isn’t so quick

For avoiding the germs there’s no trick

     If you know one, please wire us

    To prevent a bad virus

Even the doctor gets sick.

I’m frequently asked, “How do you doctors keep from catching all those germs you’re exposed to?” 

The answer is that we don’t.

Over the last two weeks I’ve been seeing a lot of patients with cough, sore throat, myalgias (=muscle aches), with or without fever.

Hand washing is important, but only so many hundreds of patients can cough in your face till you catch something.

Symptoms started about a week ago with runny nose and a dry cough.  Three days ago the cough got worse.  At band practice day yesterday I was losing my voice.  Overnight I ran a low fever but had terrible aching, with a severe sore throat in the neighborhood of my thyroid, not up by my tonsils.  When I woke up I didn’t have a voice.

If I can’t talk, I can’t work.  Most of the time if I just feel lousy I’ll tough it out and go to work.  I won’t work if I’ll endanger my patients or if I have a fever.  Five years ago I had my gallbladder out on a Friday and I was back seeing patients on Monday.

 At the same time I’m losing my sense of indispensability I’m starting to be kinder to myself in the workplace.  I took the day off and spent most of it sleeping and hydrating.  I made sure I got up and went to the cafeteria to get lunch and supper, even though my appetite is down.

But I also missed the last day of Nalukataaq (see my posts earlier this week). Though last night I got as far as suiting up (38F and 20 MPH winds) I didn’t go.  Tonight I just didn’t want to go out

My boss was very understanding, and even brought me some Tylenol (=acetaminophen).  Right now my aches are gone and I’m feeling better. 

The experience gives me both more and less sympathy for my patients.  Yes, the aching is significant.  No, it doesn’t need narcotics.

Not surprisingly, I started getting sick twenty-one days after my arrival here.  The three-week rule still applies.