Posts Tagged ‘ear wax’

New Job, First Week

June 13, 2018

I laughed, and said with a snort

In the square of the town there’s a court

You could call the town small

There isn’t a mall

And friendly comes by the quart

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, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I saw a distressing number of serious pneumonia cases during my first week on the new job. Each patient presented differently, each brought in a life story from a family context.  And each challenged me in a different way.

We have exceptional pneumonia vaccines that don’t prevent pneumonia nearly as well as they prevent death from pneumonia.

In the last 40 years the disease has changed a good deal, and we’ve reduced the death rate, but not nearly enough.

The history and physical make the diagnosis more than anything. We listen for a crackling sound as the patient breathes in, but mostly we listen to the patient’s narrative.  Still we get blood counts, blood cultures, chest x-rays, and occasionally CAT scans.  A new blood test, pro-calcitonin, helps a lot but hasn’t made an appearance in any facility where I’ve worked.

I disappointed several patients by not finding ear wax.

I have acquired a minimalist approach to medication at this stage in my career, an approach that many of my patient appreciate. I especially enjoy stopping statins, a class of cholesterol-lowering drugs that can stop heart attacks and strokes, but will not prevent a first one after the age of 65.

The facility has a small staff and a small footprint. I counted 36 steps from my office to the ER, and 6 steps from ER to radiology.

I get a steep discount on meals, reasonable cooking served in reasonable portions.

Various licensing details have insulated me from the worst of the Electronic Medical Record (EMR) headaches, and I get to dictate my notes.

A small parking lot separates my accommodations from the ER; a landline assures good communications in the unlikely event of a sound night’s sleep.

I haven’t run into marijuana problems yet. Smokers constituted a surprisingly small proportion of the patients.  Not surprisingly, binge drinkers here, as everywhere, have difficulty with insight.

The facility has a gym, a CAT scanner, anesthesia, and a surgery program. I worked with two of the nurses here during my days in private practice, and I established a relationship with the radiologist during one of my other assignments.

Most of the referral traffic will go to Sioux City, where I still know many consultants.

And there’s an absolutely first class pizzeria about 20 minutes away.

 

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Spanish, spinal manipulation, and zoonoses

January 24, 2018

The patients come in, I’m a doc,

And I ask, Are you working with stock?

Do the animals thrive?

Are they even alive?

How big is your herd or your flock?

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, and now I’m living at home and working 48 hours/week in rural Iowa. Any identifiable patient information has been included with permission.

(Post generated week of 1/15 and held till now.)

I faced subzero temps and 40 MPH winds on the drive into work today. Still I came in to find my morning schedule full.

Which conflicted with a complicated ER patient, requiring hospitalization, and, eventually, a very complex transfer. So today I started counting the steps between my clinic work area and the Emergency Department.

The steps added up to 100 each way, but I lost track of the number of times I made the round trip.

Midway through the morning, I noted a holster with a pair of pliers on a patient’s belt. Obviously a quality piece of leather, and just as obviously worn daily for many years, I made the observation that even an American-made pair of pliers has a finite life expectancy if used often, and asked how many pairs of pliers he’d been through.  He chuckled.  He’d been through three pairs so far, and the holster had been custom-made for him.  He gave me permission to recount our conversation.

A lot of farmers and other agricultural workers come to see me. The rules on antibiotic stewardship do not apply to people who work with livestock.  I have concerns not only with zoonoses (diseases acquired from animals) but with the hazard to the animals if the patient transmits microbes.   I generally don’t give out antibiotics for respiratory infections under 5 days duration, but I make exceptions, for example, for those who have just removed thousands of dead or dying pigs from a hog confinement. So along with asking if a person uses tobacco, or if a woman might be pregnant, I ask, “Do you work with livestock?”

Today was a good day for speaking Spanish, relieving suffering among patients from teenagers to septuagenarians just with my fluency. I fielded the usual question:  Where did you learn Spanish (high school, but I’ve been practicing for 50 years), and also, Are you Cuban?  (no).

At one point a non-physician clinician needed an interpreter while I worked my way through clinic, and the nursing staff activated a video service. When I returned 40 minutes later I immediately recognized an accent from Spain, but I did not get a chance to chat up the interpreter.

By the end of the morning, I had cured three patients before they left (ear wax removal for one, and spinal manipulation for two). But the ER patient would stay another 3 hours until transfer could be arranged.

I left in the dark, in subzero temperatures, ferocious winds, and a light snow.

Apology and an abnormal thyroid

October 25, 2016

A veteran I might legally be

Does it feel like that?  Not to me

I sure owe a debt

To the Viet Nam vet

Without any PTSD  

 

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. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor.  I just returned from a moose hunt in Canada.  Any identifiable patient information has been included with permission. 

I cleared out most of the month to take some holidays, but I accepted a couple of days’ work in a rural clinic not far from home.

I didn’t get formal training on the Electronic Medical Record. It turned out it didn’t take much to get me going.  They let me dictate my notes and they let me work with a nurse who knows her way around.  It doesn’t hurt that I’ve learned 12 new systems in the last 24 months.

I made that observation to a colleague involved in the residency, who noted that our Family Practice residents have to deal with 7 different systems.

The first day I worked in the new venue, I massaged away the headaches of two patients, and helped two others by taking out ear wax. In the evening, I saw three patients in the ER, two of whom required hospitalization and consultation the next day.

The pace of work went well that next day, and I drove home in a reasonable time frame.

Bethany came with me when I returned at the end of last week, driving past corn and soybean fields in the early stages of harvest.

Doctors can take some pretty rough verbal treatment, and an apology first thing in the morning made my day.

I did several pre-op evaluations. In one case, my findings came so markedly unexpected I had to call the surgeon to formulate a plan.

I cared for a Viet Nam combat vet with no Post Traumatic Stress Disorder. I told him how highly I regard the VA.  I see him as a Real Veteran but I don’t see myself that way.  He reassured me that anyone who has to put up with owning a uniform, and having a rank in a system with bad pay and bad management  qualifies as a Real Veteran.  We had a good discussion about emotional resilience and how it plays a big factor in PTSD.  He gave me permission to write about more than I have.

Even if I can’t write about people, I can write about medical conditions. I really like finding abnormal thyroid results.  Because a thyroid gland, either over- or under-active, can cause a lot of different symptoms.  When my thyroid went into overdrive, I could not sleep, I lost weight, I had no inner peace, and I couldn’t sit still.  I know that, sooner or later, my thyroid will quit working and I’ll need to take replacements.  And at the end of the day, the nurse handed me a slip of paper with an abnormal thyroid result, which explained a lot but not all of the patient’s symptoms.

 

 

 

Trade offs in Urgent Care

August 11, 2015

I enjoy my Urgent Care job
The patients come by the mob
But sometimes it’s our fate
We’re not done, but it’s late,
The rush just makes the staff sob.

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. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

I enjoy my current gig for an Urgent Care facility in suburban Pennsylvania.

My nominal work hours run from 8:00AM to 8:00PM. I go late on average one night out of three. Patients generally come in with problems of short duration and intense acuity. Most have a primary care provider who can’t see them in less than 3 days. Because management has developed a patient-centered approach, I do little redundant clerical work and thus I can spend a lot more time concentrating on patient care.

So far this week slow patient flow in the morning has given way to a brisk pace in the afternoon. Staff morale stays high, the big gripe comes against the rush of patients that starts after 7:00PM (about half the time). So tension builds on quiet nights as the clock ticks out the last half hour.

Poison ivy made up half the business back in June, but is now decreasing in frequency and severity. I have sewn up a lot of finger and hand lacerations. Two or three times a day we have the joy of curing the patient before they leave, mostly by taking out ear wax; but we also drain an average of one abscess a day. A majority of the x-rays I order show fractures.

People around here like to vacation at the beach, mostly New Jersey,Virginia and the Carolinas. We get a significant number of patients with swimmer’s ear and urinary tract infections related to the travel and swimming. And also the worried well who don’t want to be sick while on vacation.

August brings in the sports physical crowd. Basically healthy, the rare surprise disqualifications justify the activity.

Then, sometimes, with such a high patient volume (I consider 30 in a 12-hour shift light), serious illness demands an ambulance or an injection. Twice so far today I’ve advised patients to go directly to ER.

Earlier this week I helped wheel a patient into her waiting vehicle. I enjoyed breathing the warm summer air and smelling growing vegetation and seeing the summer thunderheads building in the north.

Occasionally a physical finding I’ve never before seen heralds a puzzle, and I refer to a specialist.

We refer all broken bones to orthopedists.

Urgent Care has its share of joys but so much of the fun comes from the fast pace and the easy-to-solve problems that the awe and mystery of unraveling complex disease one lab result at a time gets lost. An upscale, insured population obviates the opportunity to serve the under-served. And I miss speaking Spanish.

Life always involves tradeoffs.

Another road trip 10: starting with drama and finishing with a friend.

June 17, 2015

I started the day off with drama

For me, psychological trauma

But then at the end

I made a toddler a friend

And impressed the papa or mama.

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. I spent the winter in Nome, Alaska, and I just finished an assignment in rural Iowa. Right now I’m working in suburban Pennsylvania, combining work with a family visit.

Bethany and I boarded the elevator this morning, and another passenger came on.  I looked at his name tag lanyard and recognized the monogram logo.  I looked closer and saw the words “Health Care.”

“You rep for GE?” I asked him.

“Yes,” he answered, grinning.

“Centricity?”

“Yep.”  He still smiled.

I will confess to evil thoughts that I trace to my involvement with that EMR system.

I fantasized picking my laptop up, throwing it as hard as I could through the glass window and into the street, timed just right so that a speeding semi going 70 mph on a city street would smash it on the grill.

I have imagined walking up to the promotional booth at the American Academy of Family Practice, and starting a strident, offensive series of questions, accusing the rep of complicity with the Forces of Darkness, and I would be joined in a matter of minutes with hundreds of sweating, frazzle-haired doctors carrying signs and chanting louder and louder until, screaming, we dismantled the booth.

Or, better yet, getting a humbled software engineer into the clinic and showing him how badly the system worked and kicking him in the shins and saying, “Why would you bury landmines in a sandbox?”

In the time it took for a hundred things to run through my mind, I decided to say, “I left a job because of that system.”

His grin didn’t dim.  “We don’t sell it anymore.”

I had to stop my runaway emotions in their tracks.  My grim imitation of a smile broadened to genuine and I laughed.  “You absolutely can’t imagine how validated I feel.”  I shook his hand and thanked him profusely.

***

I can’t write anything specific about the first patient of the day, but I can say things started unexpectedly early with unexpected drama.

After that, the pace slowed till 11:00AM.  While I ended up caring for 39, the majority came in after 5:00 PM.  Poison ivy accounted for half the business, earache for another quarter, and eyes for 10%.

Removing ear wax, making the patient better before they leave, brings me great satisfaction across a wide age range of patients.

But the clinical highlight came with a frightened 20 month old.  I played my way through the exam, I finished with more energy than when I had started, and left the patient more trusting of doctors.  The parent, impressed with my gentleness and patience, gave me permission to write that, and a good deal more.

Protected: Unemployed but not out of work

October 8, 2014

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Chocolate, tornado, lemonade, ear wax, and a supervisory visit

May 3, 2011

Don’t even try to refute,

For this there is no dispute

     Could I get any closer?

     I tell you, No Sir!

Happiness is a shorter commute

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  After a six-week assignment in Barrow, Alaska, I’m working on the North Island of New Zealand.

I started the day at leisure with a seven-step commute to my office.  I sat down promptly at 8:00 AM and started to review lab work.

In the quiet of the morning, early, before the first patient arrived, I found an alarming erythrocyte sedimentation rate (ESR) with the highest C-reactive protein (CRP) I’ve ever seen; both markers of inflammation throughout the body, I prescribed prednisone.  I don’t prescribe that medication often, and always in the context of getting a specialist’s opinion.

I can’t talk about patients and their medical problems without permission, but I can talk about myself and about medicine.  Yet diseases don’t come to me, people come to me; none of them perfect, each with flaws, quirks, a terrific back story and a family.  Every person who seeks my advice has a unique smell, voice, accent, style of dress and body language.

If a person presents with an ear wax problem, and I take the wax out with a simple instrument called an ear curette, I’ll tell them how to keep the wax problem at bay.  I make sure they’ve never had a hole in their ear drum and I instruct them to start with body temperature water and put in enough white vinegar that it smells like vinegar but not so much it feels cooler.  Then, I say, use a bulb suction syringe to rinse the ears out about once a week.

I saw another person today with appendicitis, making three since I arrived.  At least, I hope I saw the first case of appendicitis I’ve ever seen in a person who had enjoyed their lunch.  I worry that my patient has something worse.

I saw a person with a single distended vein where I’ve never seen one before.

I made referrals the general surgeon, ophthalmologist, urologist, neurologist, and orthopedist.

At mid-morning, I took a tea break.  While the fifteen minute hiatus comes built into my schedule, most mornings I use it to catch up.  Today I walked back through the apartment, picked a lemon from the tree, came back in, made hot lemonade and sipped it while I talked with Bethany, nibbling on some exquisite dark chocolate macadamia nut bark.

When noon came round we lunched while we watched the shocking, driving rain outside.  The first thunder we’ve heard since we arrived made us stop and listen.

The rain continued for the afternoon drive to Wellsford.

In accordance with the Medical Council of New Zealand rules, any doctor new to the system requires supervision their first year.  In this case my supervisor is the clinical director, and we met in the early afternoon.

I enjoyed the interview. 

A reasonable clinical pace.  I told people on asthma medication to quit smoking.   I gave others with high cholesterol levels instructions about diet and exercise.

Driving back to Matakana in the rain, we learned that the same storm that gave our afternoon’s deluge spawned a tornado, so rare in New Zealand that rating came only with difficulty.

Left-sided trauma, skin infections, paperwork for income, and a surgical emergency at the end of the day

March 30, 2011

I will not belittle or curse

Nor whine when it comes to my purse

     I won’t cry or scream

     I work on a team

And I can delegate to the nurse.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  Just back from a six-week assignment in Barrow, Alaska, the northernmost point in the United States, right now I’m in Leigh, New Zealand and working in Wellsford, Matakana, and Snell’s Beach.

Today I attended twenty-seven patients.

Four asked me to fill out paperwork so that they would get an income from the government.  One denied any medical problem so clearly that I suspected some agency had recruited a patient to try to trap me into bad practice, and I refused.  For the others I advised lab investigation, retraining, and lifestyle modification.

Nine patients had superficial skin infections.  I heard the term “school sores” applied to a painless blister that rises, then drains pus, and starts to spread.  I prescribed a lot of mupuricin (Bactroban).  Three patients had fungal skin infections, and I prescribed clotrimazole, available back home over-the-counter as Lotrimin.

The vast majority of the trauma I saw happened to the patients’ left side, and included fracture, sprain, bruise, cut, and contusion.

I learned that cigarettes go for $12 per pack of 30, and that those smokers who protest they can’t afford medical care don’t like me getting out the calculator any more than the smokers at home do.

I calmed three children by playing with my yoyo.

Freezing off warts, a simple operation that requires about fifteen minutes of training, pays obscenely well at home because our system rewards procedures more than cognitive-based actions.  Today I had the delight of sending a patient with warts to the practice nurse, who was happy to apply liquid nitrogen.

I sent two patients to the Ear Clinic for wax removal.  I’ve written other posts about the satisfaction that comes from getting out a really nasty hunk of cerumen, but I never detailed the occasional frustration and back pain that goes along with it.  The frequency of ear wax impaction justifies dedicating a nurse three days a week.

I checked patients’ blood pressures today.  For twenty-three years I could say, “Vital signs?  That’s the nurse’s job,” but I’m in a different framework here.  The nurses have a lot more responsibility and power.  They do a good job and free me up for other things, and I don’t mind if I pay the price of collecting all the vital signs I want.

At five, as I settled down to complete my documentation for the day, a nurse asked me if I’d see a patient.  The doctor on call had stepped out.  Not a problem, I said, and saw an opportunity to demonstrate good team work. 

I can’t write any of the specifics of the case because I didn’t get the patient’s permission. But I can say that the nurse did a good workup and that I had the satisfaction of going one layer deeper to uncover a true surgical emergency.

I had seen a couple similar cases a year ago, and even in my own clinic and zone of comfort, my emotions ran high.

Currently, I have limited access to the Internet. 

A nose full of jelly bean, an ear full of wax, and parasitology vies with heart failure in the morning

February 23, 2011

A toddler will try, I suppose,

To stick jelly beans up in the nose

      With patients in stacks

     We take out ear wax,

While outside the arctic wind blows.

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.

Long before dawn (the sun rose about ten today), with the mercury firmly at -28 F (-33 C), the physicians of Barrow sat down together in the hospital’s Commons Room.

We start clinic days with a conference, an hour discussion of patients who need to be brought to the group’s attention.  Sometimes the debate runs hot.  No two docs have the same range of skills; we all come away from the discussion better physicians.

The hour, for the last week, now features a five-minute starter from the Case Manager, giving us updates on the patients sent to Alaska Native Medical Center (ANMC) for hospitalization. 

We don’t talk about drama and irony nor contrast and meaning, though we talk about the impact of illness and injury on people’s lives. 

We focus on diabetes and smoking, emphysema (which we call COPD or chronic obstructive pulmonary disease) and steroids, heart disease and the interplay of factors that bring a person to illness.  Occasionally we’ll talk about tragedy and trauma and domestic abuse.

Narcotics seeking behavior comes up a lot, but as a group we’ve evolved a way to deal with the problem.  Part of the solution includes the doctors communicating with each other.

One doc gave an erudite rundown on congestive heart failure, renal physiology, and hypertension.  He did it as casually as giving directions to the gas station.  An in-depth round table on practical parasitology followed 

Morning appointments follow morning conference.

My last patient before noon survived burning, stabbing, shooting, being run over by a riding lawn mower, and falling from a roof and bouncing (and gave me permission to use more information than I’m including ).  After all that trauma, his lifestyle choices threaten his life more than anything else that has happened.  I called a specialist in another city, and, in the spirit of full transparency, included the patient in the conversation by leaving the speaker phone on. 

 The specialist said a lot of things he wouldn’t have if he’d known the patient were listening, like using the phrase, “stupid idiot,” but he also gave a good if emotional rundown of the physiology in the case.  I watched the patient’s face, he seemed neither offended nor surprised.  I respect him as a man of remarkable emotional and physical resilience, whose intelligence has not been ruined by schooling.  But I disagree with a lot of his choices. 

Afternoons, the clinic opens to walk-ins with no appointments necessary or available.

Ears, nose, and throat problems dominated the afternoon.  One patient left cured after ear wax removal.  Four others had ear infections.

The mother of a young girl gave her OK to post the following: the child inserted a jelly bean into the nose.  Toddlers imitate reflexively though their first response to a command is No.  I held one side of the mother’s nose shut, with a tissue guarding my hand, and had her blow through the other nostril.  Given the opportunity, the kid did the same thing, and the jelly bean, its colorful sugar coat dissolved, shot onto the paper.

I don’t often get the chance to cure patients before they leave.

Foil on windows, wax in ears, blood in the nose

June 13, 2010

The patients get sick, we know why

From the outlying village they fly

     Those on four wheelers

     Need the help of the healers

The North Slope is not really dry

Most of the twelve-hour call shift yesterday was reasonably paced.

Weekend medical staffing here covers Emergency Room and what is locally known as Walk-in Clinic.  Heart attacks and ATV accidents, for example, go to Emergency Room and colds, earache,  and allergies go to Walk-in Clinic.  Although the two things happen within steps of each other, and use the same paperwork and staffing, they are conceptually separate. 

The reality of Barrow and the bush hurt people in unique ways.  Four wheelers are a part of life on the North Slope, pavement is not.  Accidents happen and bones break.  Despite the high cost of cigarettes, $100 a carton, people smoke a lot.  They get emphysema and heart attacks.  Soft drinks are consumed by the rack (24 cans) or half rack (12); teeth rot, diabetes and its complications set in, obesity is common.  (My clientele in Sioux City also used an insane amount of soda pop.)  They cut themselves dealing with waterfowl and fish and get peculiar infections.  Alcoholism stumbles side by side with complete abstinence.  I took care of an 8-year-old who weighed twenty pounds more than a 51-year-old.

I talked to people whose relatives died in the tuberculosis and meningitis epidemics.

We sent a patient to Anchorage via Medivac; we had another fly in commercial aircraft from an outlying village.

On three occasions I spoke with Community Health Aides.  Each of the outlying villages has one.  Most are EMT’s, some are paramedics. 

I took care of a patient yesterday with a severe nosebleed, using 1% lidocaine with epinephrine rather than cocaine.  I cured a patient’s earache by taking out a piece of ear wax the size of the patient’s pinky finger.

I admitted a patient yesterday with half a dozen major diagnoses.  I’ve ordered some labs that won’t be back for a week or two.  On rounds this morning the patient is feeling better, but not well enough for discharge.

Being a non-Arctic resident, I admitted defeat in the presence of twenty-four hour daylight and took a trip to the grocery store.  I needed a roll of aluminum foil and a roll of duct tape, and as long as I’d taken the taxi there, I couldn’t pass up a bag of cherries.  And a bag of dark chocolate squares.  Fifty bucks.

I also visited the Cultural Center, a very nice facility.  Being sixty, they consider me a senior and let me in free.  I bought a T-shirt saying “I had a whale of a time.  Barrow, Alaska.”  There’s a one hour show for the tourists who come in with Top of the World Tours; I’ll go with Bethany when she comes.