No such thing as a free breakfast

Uncle Sam sure lied to me
And paid me a much smaller fee
I didn’t know what I’d get
Because I’m a vet.
Still, free breakfast just wasn’t free.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, two weeks a month working Urgent Care in suburban Pennsylvania. Any patient information has been included with permission.
On Veteran’s Day, Bethany and I went out to a chain restaurant that offered a free breakfast to veterans. I brought my VA card.
Ankylosing spondylitis kept me out of the war in Viet Nam. Later on, when I sought to enter the Indian Health Service, I believed them when they said that I could only get in if I went as a Commissioned Officer (they lied); ankylosing spondylitis would have disqualified me, but a report from a shaky radiologist sealed the deal, saying “no evidence of sacroiliitis.”
The Department of Defense (DoD) controls 5 of our Uniformed Services (Army, Navy, Air Force, Coast Guard, Marines), but not the Public Health Service (PHS) or National Oceanographic and Atmospheric Administration. My service in the PHS qualifies me for Veterans’ benefits at the VA, and the VA has been very good to me.
In fact my IHS service units had Civil Service employees working the same job as Commissioned Officers. They got overtime past 40 hours a week and started with more than twice the base salary. All in all, my naivete cost me more than a quarter million dollars early in my career, but the value of my VA benefit is catching up. And I count my time as a Commissioned Officer as priceless.
There is no such thing as a free breakfast.

On the road again, so soon: South Bend and Advanced Trauma Life Support

I drove all the way to South Bend

Through the snow and the dark I did wend

    I went out to learn

    About trauma and burn

And the latest emergency trend.

I took the Advanced Trauma Life Support (ATLS) course in South Bend, Indiana, this weekend.

The clinical staff of the hospital in Keosauqua, my latest locum tenens job, arranged for me to leave early Friday afternoon, and I kept ahead of the freezing rain, arriving in the dark and the snow.

I finished reading the 360 page book, as recommended, and I skimmed the information again once I got to the hotel.

Ten doctors and eight nurses attended the course.  One, a second-year surgical resident, had left call, driven four hours, and arrived in time to nap before the class started. 

I took the class in 1985, shortly after its inception, and I found a few changes in nuance.  Course doctrine demands keeping the patient from contracting hypothermia during the resuscitation.  Head trauma no longer requires steroid therapy.  Military Anti Shock Trousers (MAS pants), so important thirty years ago, later reviled, have made a small comeback, renamed Pneumatic Anti Shock Garment.  Diagnostic Peritoneal Lavage has almost disappeared, largely replaced by the Focused Abdominal Sonogram in Trauma (FAST).

Much has not changed.  Fluids for shock, needles for cardiac tamponade, chest tubes for blood or air outside the lungs; the first three priorities remain airway, breathing, and circulation.

Six hours of lectures the first day, followed by four hours of practicing skills on plastic dummies and reading x-rays.

The second day brought another six hours of lectures.  Then we worked with simulated patients, attractive young women with moulage wounds.

The author, foreground, with a person moulaged to simulate a patient involved in a bad car wreck.

One case scenario supposedly involved an eighteen-year-old meth addict sustaining three rifle shot wounds at close range after a bungled liquor store robbery.  I worried because I didn’t see exit wounds.  I handled the challenges OK, establishing a definitive airway first, moving onto a chest tube and arranging for transport to a trauma center.  At the end I saw the x-rays, derived from a real case.  Three retained bullets, to my practiced eye, obviously had exited the barrel of a handgun, not a rifle.  Realistically, few people with three rifle wounds will survive long enough to require medical care. 

I took the written test.  People don’t get into or out of medical school without being good test takers, but exam scores have little to do with real world ability to care for patients.

In the Indian Health Service, the ATLS course and the subsequent five-day “mini-residency” helped me save three people who encountered the undeniable physical realities consequent when flesh and bone try to occupy the same space as decelerating steel. 

I drove back to Keosauqua, in the southeast corner of Iowa, in the dark and the snow, hoping I would never have to use the skills I’d just learned.