Posts Tagged ‘game theory’

Fixing a calf cramp

October 9, 2017

Type and cross has a 2 hour lead

So if a transfusion the patient might need

Stay 2 units ahead

So they don’t end up dead

If the gut gives rise to a bleed

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to traveling and adventures in temporary positions. Assignments in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska have followed. I just finished 3 months in northern British Columbia, getting a first-hand look at the Canadian system. I’m now back picking up an occasional shift in northwest Iowa.  Any identifiable patient information has been included with permission.

“Always stay 2 units ahead of a GI bleeder,” they said in med school and again in residency. Many years and much experience has not diminished that truism, which to this day shines as an example of game theory.  It means that when a patient loses blood from anywhere in the gut, from the esophagus (swallow tube) to the rectum, that the physician must stay prepared to transfuse 2 units (a liter, close to a quart) of blood.

One can’t transfuse blood without first typing and cross-matching the blood, a complicated lab procedure that takes 2 hours. (For one extreme trauma patient in another country, I ordered the hospital’s entire stock of 5 units of O negative blood, the so-called universal donor type.  But that country has a very different legal climate, and I had no other options.)  You can lose the patient in the time it takes to do the test.

This weekend, I had a patient come in with profuse painless blood in the stool. My small rural hospital has a very limited blood bank, and the ride to the referral hospital realistically takes 2 hours.  I explained to the patient that transferring a stable patient beats transferring an unstable patient, and asked for permission to write about the case from the perspective of how doctors make decisions.  She gave me permission to publish the entire case, and pointed out that Facebook would probably have her room number before she arrived at the referral center.

(Her family history has a disease so rare that to name it would name the patient.)

The mathematical discipline of game theory has a whole branch dealing with games of incomplete and imperfect information. The real world of medicine deals with those circumstances.  I have to live with the limit of what can be known in the time allotted in the place where I work.  I know I never have the whole story and that patients never give a completely accurate history.  I have to work with what I get.

Thus I deal with the certainty of uncertainty.  I can’t know if the patient’s bleeding will worsen or stop by itself, nor if problems will arise during transport.  I have to look at probabilities ranging from worst to best case scenarios.

The paramedics arrived, and greeted the patient by name. Everyone knows everyone here.  As the patient shifted from the gurney to the stretcher, a cramp seized her leg, and she asked the paramedic to massage her calf.

“I can make that cramp go away,” I announced, perhaps with too much assurance. But I took the outside of the middle of the patient’s upper lip as close to the nose as I could, between my thumb and forefinger, and squeezed.  Fifteen seconds later, her calf cramp disappeared.

I think that I unduly impressed the nurses and paramedics,

I learned that acupressure trick early in my career, but I don’t remember where or when. Probably before I learned to stay 2 units ahead of a GI bleeder.

 

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I take call and end up a patient.

April 23, 2017

At the end, it wasn’t a stroke

It was gone when I awoke

The symptoms were brief

Avoiding much grief

And I got to tell a crude joke.

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.

 

Tuesday evening while on call, I got up to play Scrabble and I couldn’t make my right leg work. It didn’t feel heavy, numb or weak; it felt too light so that any effort to move it got exaggerated.   I sat down to do a neurologic exam on myself.  I found nothing other than my right leg ataxia.  I called Bethany from the next room, and told her the situation.  She helped me dress, and drove me to the ER.

The ARNP covering the ER did the same neuro exam I did, which wasn’t impressive until I demonstrated my gait.

She did all the right tests. The first EKG showed an old heart attack, which disappeared with proper lead placement.

She also found a heart murmur.  It hadn’t been present 5 years ago, but the PA at the VA found it a couple of months ago, and I called her attention to it.

My blood work had no surprises. She offered me the choice of staying in Clarinda or going into Council Bluffs, and I chose to go.  In terms of game theory, if something happened in the middle of the night, I wanted to be close enough for timely intervention.

In the process I had to make arrangements for someone else to take call.

I napped off and on for the ambulance ride, which almost got derailed twice by herds of deer. I bypassed the ER at Jennie Edmundson Hospital.  At 2:00 AM I had gotten settled, my IV had given me a couple of quarts, the second set of labs had come back and I’d had a good visit with the hospitalist ARNP.  Just before being tucked in, I offered the nurses a choice between a clean joke, a clean joke with a bad word, or a dirty joke.  They chose the last option, and I gave them the funniest crude joke in my large arsenal.

I don’t get to tell that joke as a physician, no matter how funny it is. But, as a patient, I can get away with it.  The punch line drew gales of laughter.

By then, motor control of my right leg was functioning at about 90%.

I slept for a couple of hours and had breakfast.

The neurologist arrived, and with economy of motion, did a thorough exam. He advised an aspirin a day and starting a low dose migraine medication.

The morning parade of tests started. By the time Bethany arrived I had done the basic neurologic exam six times and the symptoms had resolved except for the funny feeling inside my head.

I had an ultrasound of my neck, a consultation with the dietician (whom I amazed with my six pieces of fruit a day and my two ounces of salmon at breakfast), a consultation with the Occupational Therapist, and then the Piece de Resistance, the MRI. In between, I napped because I’d slept so lousy.

The hospital feeds its patients on the room service system; I ordered a lunch of soup, sandwich, and fruit, and within a half hour a young Guatemalan arrived with the food. We had a brief conversation in Spanish, I introduced my wife.

And we waited. The hospitalist came back, and went over the results.  Ultrasound demonstrated clean carotids (neck arteries).   The MRI didn’t show anything conclusive.  He also recommended an aspirin a day.

We waited for echocardiogram results. The hospital public address system announced a severe thunderstorm warning, and then a tornado watch in effect till 10PM.  The internet and the TV weather agreed that severe weather approached from the west.  At 4:45PM we decided to leave before the storm arrived, without the echocardiogram results.  We didn’t want to spend the night in the hospital, nor did we want to risk hitting deer on the way back to Clarinda.

Bethany drove. We enjoyed dramatic skies and listened to a Continuing Medical Education CD.  We ate at Clarinda’s premiere restaurant, J Bruner’s, ordering off the appetizer menu.

I returned to work the next day, the episode completely resolved, making it a transient ischemic attack (TIA), also call a reversible ischemic neurologic event (RIND).  Except I noticed my handwriting was much clearer.

I don’t think anyone else noticed.

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

January 6, 2017

Blog 2017 January 5, 2017

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

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

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

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

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

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

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

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

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

Misnomers, eponyms, and radio traffic

February 12, 2016

We started out doing rounds

Exploring our intellectual bounds

It’s not a misnomer

To call a vomer a vomer,

No matter how silly it sounds.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. Just finished with 2 months in western Nebraska at the most reasonable job I’ve ever had, I am back in coastal Alaska.  Any specific patient information has been included with permission.

Yesterday before 10:00 AM I had to research two diseases I’d never heard of before, and I didn’t attend a patient with either.

Medicine uses its own language. Some nouns, like vomer (the midline bone in the nose) have no other synonym.  Ideally one could discern the nature of a disease by its name; viral hepatitis, for example, means liver inflammation caused by a virus.  But if we call a malady by someone’s name, such as Parkinson’s disease or Lou Gehrig’s disease, we say that we use an eponym.  And we call it a misnomer if the disease isn’t what we call it, for example, a pyogenic granuloma is neither pyogenic nor a granuloma.

Another provider held up an x-ray report and pointed to a term, asking if I’d ever heard of it. I chuckled and asserted that surely the transcriptionist meant either fracture or infarction instead of what appeared in black and white, infraction.  So I looked up the eponym, only to find that the transcriptionist had typed correctly.

The other term, including an Alaskan place name, got thrown around during rounds. I had heard of the body of water, but not the syndrome.

The medical staff gets together every morning, much as we did in Barrow and each meeting makes me a better doctor. We talk about admissions, births, deaths, and interesting cases.

For the second time this week, we threw the term Wernicke-Korsakoff around without making that diagnosis.

When we talk about what might be wrong with a person, we use the term “differential diagnosis,” meaning the things that could give rise to a particular clinical picture. In conversation, we shorten it to “differential.”  In the process of dialogue, we draw on each other’s experiences and knowledge at the same time we go through our reasoning process.

After rounds I nipped out to the airport to pick up Bethany, then I came back to find that I had drawn the position of second call: help out the first call doc if overwhelmed, and take care of radio traffic.

The term radio traffic qualifies as a misnomer because we use telephones where previously radios had done the job. Dozens of villages look to the town as their hub for business, health, and air travel. Every village has a clinic staffed by a Community Health Aid or a midlevel practitioner. Each permanent doc serves as consultant for more than one village, but the second call physician converses with the clinic when the assigned doctor goes on vacation.  And right now the hospital finds itself short-handed.

I sat in the medical staff office. I cleared up documentation and read through the scores of emails that had arrived before I did.  I looked at the corporate website, and checked weather reports.  I read through some informative threads on Sermo.com, a doctors-only website.  At noon I went to a Continuing Medical Education lecture on diabetes and the new class of drugs, incretin analogs.

At one I had a few phone calls, and I phoned around to a dozen clinics.

And I drew on my experience with game theory to make decisions based on incomplete and imperfect information.

I did a necessary job, but I prefer face-to-face human contact.

 

 

Another road trip, day 1

June 5, 2015

In the car I picked up some calls

As we drove past fields and malls

To make a decision

Without info precision

I requested an ethical stall

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. Since then I’ve done a couple of assignments in rural Iowa, and one in western Alaska.

Bethany and I rocketed east at highway speeds.  The crops still too immature to tell soybeans from corn, the fields have acquired a definite green hue, the brown of the dirt still barely visible between the rows.

A call came through the miracle of Bluetooth and car electronics; a colleague had discovered the perfidy of the recruiting agency.  I worked at that venue for a while, we agreed the work, the staff, and the administration make the clinical side enjoyable.  The town itself we found unique, exotic, and fun.  But we also agreed that we don’t want to work with that agency again.

In this country at this time, when a healthcare facility finds a need for a doctor, they turn to an agency.  If the agency successfully recruits a doctor, they get a large fee from the client, from which they pay the doctor (as an independent contractor), get him/her to the gig, put him/her up once they get there, rent a car if necessary, and finance professional liability insurance.   They also vet the candidate.

They deserve money for their services.  However professionalism runs a spectrum amongst recruiters, and, regretfully, among agencies.

I went to New Zealand through the government-financed agency NZLocums.  They took money from neither doctor nor client, and put me onto a couple of really sweet assignments.

Another, private enterprise agency placed locums docs in New Zealand at that time; they took a commission of about 1/3 and, in return, made sure the immigration process went smoothly.

Later in the day, another call came through from Canada.  Like New Zealand, this province has a government-funded agency to help bring in doctors for short-term assignments; they exist on tax dollars rather than commission.  But I’ve been working with a small, private agency that collects a finder’s fee from the client and lets the doctor and the facility negotiate their own contract.

The person I talked to from the government-funded agency expressed a good deal of unhappiness that I would work with the private firm, told me in no uncertain terms that I couldn’t go through both, and tried to pressure me into making a choice immediately.

I declined to do so, but Bethany and I discussed it as we drove.

We reasoned that on the New Zealand analogy we’d face a tradeoff between the two choices: once would probably offer more money and the other would probably offer better service.   But in a game of imperfect and incomplete information, we couldn’t be sure of that tradeoff, nor of the degree of the tradeoff.

But I know that I don’t like the government agency’s rep’s approach;  I found it high-handed and bullying.  And I know that this adventure is not about the money.

We’ve made our decision.

Three doctors over breakfast discussing contracts, diabetes, trauma and hearts

August 31, 2014

At breakfast sat down doctors three
The advice that we gave was for free
We talked about cases
And contractual places
And what we should charge for a fee.



Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I still take short-term positions occasionally.

Three of us met on a Thursday at a popular coffee spot. Over trendy breakfast items and flavored lattes we discussed game theory and negotiating techniques.

A couple of Thursdays or Fridays per month have found us at a morning meal together for the last couple of years. We have guided each other through difficult items of a doctor’s career. We all face hard decisions for our lives and our life’s work.

We do not hesitate to give voice to good advice in the face of questionable choices, and we each have regretted not taking our own advice.

But yesterday we talked about getting a better offer. One who has no willingness to walk away from a deal has no bargaining position at all. We have all faced bait-and-switch situations; an employer has said one thing, made a deal, then unilaterally changed the circumstances. What can a doctor do?
None of us alone has more wisdom than all of us put together, and our group consciousness guides us to better decisions and actions.

We finished stronger than when we had started but we ran out of time and we still had cases to discuss. Because the business of being a doctor and the work of being a doctor are so intertwined. Come to my house tomorrow at 7:00AM, I said, I’ll make omelets and we’ll continue.

As dawn on Friday broke, I engineered quick but elaborate breakfast dishes. Jarlsburg cheese caramelized in the frying pan as the discussion started.

For reasons of anonymity, I will leave out who presented which patient.

An 18 year old female with thrush, or, at least, a painful mouth diagnosed elsewhere as thrush.
“Does she have HIV?” one asked. No, she didn’t, but that’s a good thought and the test came up negative. “How about the 3 P’s?” came the next question. Excellent, the presenter said, referring to polydipsia, polyuria, and polyphagia (drinking a lot, urinating a lot and eating a lot), the three signs of diabetes we all learned in medical school. Yes, she did; her sugar was 424. There followed a presentation about distinguishing Type I diabetes, where the patient will need insulin for the rest of her life, from Type II, where diet, exercise and pills can take care of the problem. We talked about 4 lab tests 2 of us had never heard of, and how the phone call to the endocrinologist (hormone specialist) went.

Then a case of wide-complex ventricular tachycardia with low blood pressure, a presentation classic from Advanced Cardiac Life Support, a course we’ve all taken. And after that, a death from massive trauma, complicated by legal and administrative issues and a difficult family situation.

As we ate mushrooms, onions, fresh basil, eggs and cheese, each of us filled in the human details, the heart-rending impact of disease as it ripples through the family, the community, and the hospital staff. By the time we finished we were better doctors.

Taking the bump: think it through

October 5, 2013

We had seats on an overbooked flight.

Would we take a bump?  Well, we might.

It depends on the price.

But the agent was nice,

And we got home just before night.

SYNOPSIS:  I’m a family physician from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout, and, honoring a 1-year non-compete clause, worked in out-of-the-way places from New Zealand to Barrow, Alaska.  Now I work part-time at a Community Health Center, meaning that I average 54 hours a week.  I just got back from a two-week working vacation in Petersburg, Alaska, and an educational convention in San Diego.

I recently took a non-credit course in Game Theory; it had major overlaps with chaos theory and economics, and a few in physics.  If I can summarize 18 hours of lectures in a one sentence: think things through.

On our way back from San Diego, the airline announced an overbooking situation and offered to pay people to rebook their flights at a later time.  Usually I don’t have that kind of flexibility, but on this occasion we had arranged travel on a Saturday, and I didn’t have clinical duties till Monday.  For the first time, ever, I could afford to take the bump.

And I could apply my new-found game theory skills.

Most other offers of cash-for-getting-bumped have come while travelling on a Sunday and have gone begging at $400 a head.  In this case,.  I decided that probably a lot of other people had flexibility and would be more willing to take the money, so that the chance of getting a large sum would go down

I hit the ticket counter before anyone else, and offered up my seat in the spirit of cooperation and greed, to the tune of $200 a head, paltry in comparison to past offers.

While I stood there, another pair of passengers came to vie for the prize.

The agent booked us on a later flight going through Phoenix rather than Houston, avoiding some bad weather, cutting the total flight time by an hour, shaving another hour off a layover, thus getting us into Omaha 2 hours ahead of schedule.

I declared, to the agent, the classic win-win situation.

Yet we still boarded the plane with disappointment in our hearts that our original itinerary would be followed.

Five minutes before scheduled take-off the flight attendant had us leave the plane; something to do with a loose seat bolt elsewhere.  We strode across the airport to a different airline’s gate, and in a few hours touched down in Omaha, richer and sooner than expected.

Just one more example of being pleased to not get our first choice.

Terrible traffic and courteous drivers, narrow lanes with gorgeous vistas, impossible situations with competent bureaucrats. Caution: contains 1100 words.

March 26, 2011

I started orientation

On the verge of final frustration

    Without enough slumber

    I awaited my number

And at last I got registration

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, hoping to start work next week. 

I slept poorly last night because of anticipation of my weekly Care Initiatives Hospice meeting, my orientation to the new clinic, my interview with the Medical Council of New Zealand, my appointment with Immigration, and the need to move at the end of the day.

We have no net access in the beautiful town where we’re staying; running out of megabytes and the noise of passing trucks marred my Skype session and jangled my nerves as I sat outside the only wireless hot-spot available, a half-hour away from our apartment.

At orientation, in Wellsford, I filled out more paperwork, came up short on the professional liability issue, the work visa, and the medical registration number.

I have been struggling with those three issues since I arrived.  Before I can have a license, the Medical Council of New Zealand wants to see me, with my original medical school diploma and my passport in the same place at the same time.  Most days dawn with the expectation that Today Will Be The Day and end with hope for tomorrow.  Four days ago frustration replaced anticipation. 

My license hung up a week ago on the fact that the hard copy Certificate of Good Standing from one of my State Medical Boards hadn’t arrived. (When I made my overseas call to investigate, the person who sent it out muttered he always had problems with overseas mail.) 

The process involves a three-way Catch-22: to have a job, one needs a license and a visa; to have a visa, one needs a job, which also requires a license; to have a license, one needs a job.  Because 40% of the doctors in New Zealand come from other countries, physicians rate enough flexibility to render the task possible.

The manager of the twelve doctor operation, Sara, glows with professionalism; calls flew back and forth, and by 11:15 I had my invitation to meet with the Medical Council in Auckland.  I could visit Immigration first as long as I had the invitation in hand.  We headed out at 11:30.

The drive took an hour and a half, through spectacular vistas. 

Auckland , New Zealand’s biggest city and four times larger than the capitol, Wellington, boasts 1.4 million people.  As with any other city that size, the traffic problem drives many to insanity.  The hyper vigilance engendered by accommodating to driving on the left didn’t help me, though the courtesy of the other drivers did.

Our GPS guided us to the proper spot but couldn’t find us a parking place.

Twenty traffic-crawling minutes later, Bethany guided me into a parking spot in a facility designed for very small cars being driven by really good parkers.

Downtown Auckland appears to be vigorous, energetic, young, and Asian, with a few Maori and Pakeha thrown in.  Sushi, tandoori, curry, and kebab restaurants crowd against banks, electronics shops, and fashion stores. 

Immigration rules from the fourth floor of a high-rise office building.  I heard languages from Korea, China, Japan, India, Germany, America, and Australia.  Dress ranged from business suit to blue jeans, footwear from flip-flops to oxfords to hiking boots.

After a fifteen minute wait in line I approached the counter with my green plastic folder full of paperwork.  Three people handled the stack, assured me that all was not in order, I would need to leave my passport, and they would send me my visa in a couple of days.

I called my agency in a panic from the counter.  “This is anything but a walk in the park with a couple of rubber stamps that you promised,” I said.  “I can’t leave my passport, I need it when I meet with the Medical Council.  They tell me you need to call Carl.”

I was told to sit down and calm down and wait.

We waited.  In the early afternoon, I knew from long experience, sleep deprivation hits after the morning hormonal surge has left.  Worst case scenarios ran through my mind, and I started to figure.

There is much to be said both for never giving up and for knowing when to quit throwing good money after bad; such is the basis of game theory.

“If I’m not working in a week,” I told Bethany, “we’re going home.”

“You sure you want to give them that long?” She asked.

“I’m figuring time investment as a percentage of time spent working,” I said.

We waited another hour.  I called my agency.  “Nothing is happening.  I’m getting upset,” I said.  Just before I said I’m giving this up as a bad bit of work and I’m going home and the heck with you, a grizzled office veteran called me.

Smiling, courteous, and professional, I relaxed in his presence.  He explained the hang-up and the work-around, and called me back to desk 6.

Two more people handled my packet, and ten minutes later, with the hologram-decorated visa pasted into my passport, we left.

Polite drivers let me edge into the crush of Auckland’s rush hour.

I faced reminders of home: lanes as narrow as the Pennsylvania Turnpike and Jersey barriers.

We arrived ninety minutes early in suburbia marked by young trees.

I power napped and brought out my computer while Bethany slept beside me.  At 5:15 I met with a Justice of the Peace who looked over my papers, handed me a 250 page tome “Medical Practice in New Zealand,” and assured me that five working days was optimistic for a license number.

Waiting for traffic to abate, we ate in a food court and I bought work shirts.  We drove out of the city, back out into the verdant countryside as darkness closed around us and a drizzle fell.

By the time we got back to Leigh the clouds had opened and rain fell in sheets.  Traveling light brings the advantage of quick packing, and before nine we had unloaded and unpacked into an incredibly gorgeous beach house with a view.

Eighteen hours later I had my license number.

This post was written on Thursday, not posted till now because of internet access problems.