Great teacher! I remembered 40 years later

So well did he teach from his zone

I still know what I had known

And it came back to me

What I did see

And could call it complex of Ghon

Synopsis: I’m a Family Practitioner from Siux 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 3 Community Health years, I took temporary gigs in Iowa, Pennsylvania, Nebraska, Canada, and Alaska.  Since the pandemic, I did telemedicine intermittently in my basement, staffed a COVID-19 clinic in southeast Iowa, visited family, attended funerals, worked at the Veterans Administration in South Dakota, held a part-time position close to home, and worked 10 weeks in western Pennsylvania.  My current gig in northwest Iowa, started in June, will draw to a close on November 9.

I arrived on the Acoma Reservation in northern New Mexico in July 1982, fresh from residency.  The Indian Health Service recruits with difficulty because of cultural conflicts, salaries, geographic isolation, and centralized leadership’s poor communication with the docs in the field.  I started with a group of 5 other physicians, all of whom came directly from training.  With one exception, we completely replaced the physician staff who preceded us.

Doctors in remote hospitals have jobs in addition to patient care, among others EMS director, infection control officer, Pharmacy and Therapeutics committee, and Lab Director.

Before the grand tides of experience could grind away the sharp-edged arrogance that comes from Passing the Boards, while we regarded the 110+ hours per week of residency as normal, I volunteered for TB Control Officer.  I got Sent for Training. 

The Indian Health Service had to maintain a training infrastructure to deal with tuberculosis because that disease had almost vanished from mainstream USA while Native American and Alaska Native groups maintained rates that hadn’t fallen much in 50 years. 

I had peripheral involvement in only one case during my training, a member of the Shoshone Nation whose doc had no experience with TB, either, and the disease advanced to tragic consequences.

The teacher who ran the training program in Denver for IHS docs knew his stuff and qualified as a teacher so gifted that 40 years later I remember his lessons.

After I left the Hochungra reservation, during my private practice years, I saw, on average, one case per decade.  An outbreak among the Inuit and Yupik punctuated my sojourn in Nome, but because of the context, the hospital had infrastructure and protocols to deal with it. 

Today I looked at a chest x-ray.  Much to my surprise, I saw a white sphere, about a half-inch in diameter, sitting towards the edge of the lung, with a cluster of similar, tiny spheres near the hilum, or center.  I recognized a Ghon complex, a rare finding diagnostic of TB.  I showed the patient (who gave me permission to write what I have).  I talked about how lucky I had been to had a teacher so good that, 40 years later, I could recognize something I hadn’t seen since 1983.

What does “call” mean? Don’t look in the dictionary

Consider the places I’ve been

Then tell me, what does “call” mean?

For sometimes the word “call”

Means nothing at all

And sometimes it can make me turn green

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.

People can use the same word to mean different things, and the same person can use a word at different times to mean different things.

For example, when I worked in the Indian Health Service, “call” started at 4:30PM and lasted until 8:00AM. Weekend call started on Friday afternoon and lasted till Monday morning.

In my years of private practice, it started at 5:00PM and went till 7:00AM. The doc who took Friday evening call worked the clinic on Saturday from 9:00AM till 2:00PM.  The physician with weekend call started Saturday as early as he or she wanted, rounded on the patients in the hospital, and took care of admissions till 7:00 Monday morning.  For a long time we saw the patients who came to the ER, but that faded over the years.  The on call doctor did the obstetrics over the weekend.

Call in Barrow (now called Utqiavik) never meant anything other than 12 hours, weekend, weekday, or holiday.

In Petersburg, the physician on call also covered the emergency room.

In western Nebraska, being on weekend call meant doing a Saturday clinic till noon, rounding on patients Saturday and Sunday, and admitting patients from the ER.

In Metlakatla, where we had no hospital beds, the two main ER nurses had excellent clinical skills. I could rely on them to know when I needed to come in and when I could safely wait to see the patient in the morning.

I have call this weekend, starting at 8:00AM on Thursday and going to 8:00AM on Monday. During that time, I’ll round on the hospitalized patients.  But someone else will work the Emergency Room.  If a patient needs admission, the Emergency doc does an admit note and writes admitting orders.  If a patient needs me to come in and see them before morning, they generally need to be at a larger facility.

I have had two nights of call so far. The first one passed without my phone going off, not even once.  The second time I worked steadily till 9:00PM stabilizing a very ill patient for transport.

But what does call really mean, here, this weekend?

I can tell you on Monday.

And I can guarantee it won’t mean the same thing a month from now.

A movie, an owl, and patient getting worse.

 

Last night we went out to a flick

It got prizes for being so slick

But a hoot from an owl

Who was out on the prowl

Warned of patients, who got desperately sick

 

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

Last night Bethany and I went to the two-screen theater in town and saw The Revenant, an Academy Award winning movie.

On the way out of the theater, I got a call from the hospital; one of my inpatients requested a sleeping pill. Hospitals thwart the sleep that healing requires, and I gave the order over the phone

We talked about the film on the way back. It featured a lot of action, it got some bits of woodcraft and history right, and a lot wrong.  I enjoyed the Shawnee and Arikara dialogue.  We agreed that we could have done without so much gratuitous violence.  Bethany asked some medical questions, and we tried to figure out at what point the French traders stole Powaqa.

On the net, researching the real story of Hugh Glass that served as the basis for the film, I heard an owl hoot 4 times outside the north part of our townhouse. I glanced out the sliding doors to the deck, but saw nothing.

In my years with the Indian Health Service, I learned that most Native Americans regard owls as terrible omens, bringers of bad luck and death, and the sound chilled me. The film had brought memories of working in a tribal context, bringing that milieu back into my consciousness.

But I slept soundly, because call here means nothing. The doc covering the ER handles problems in the hospital as they arise.  Thus finding a “missed call” message from the hospital from 1:00AM brought alarm.  The voice mail asked me to call back immediately.

When I got to the hospital, I found that my patient, the one who had requested the sleeper, had just been transferred out. After the ironic decision to change after decades of bad health decisions, the dramatic payment to the piper came, and the patient’s fast glissade downhill started about the time I heard the owl.  His medical needs exceeded our capabilities.

And despite all the right decisions and all the right medications, just like Humpty Dumpty, some things can’t be repaired.

But the clinic patients started well and got better. One of the follow-up patients looked and felt dramatically improved on a scheduled dose reduction.  Two people had ear infections.  Nobody quit smiling when I wouldn’t give antibiotics for colds.  I had time to do some online research about testing for cystic fibrosis, and I caught a power nap over the lunch break.

The pace picked up in the afternoon. I got to speak Spanish, and I used the osteopathic part of my training to make a person well before departure.

Without the gloom of the first part of the morning, the rest of the day wouldn’t have gone so sweetly. Contrast is the essence of meaning.

 

Road trip 2: Cincinnati to Pittsburgh. On dealing with a flakey recruiter

I said yes but I’m waiting to hear,
While I drive and I brake and I steer,
Not quite my ideal
But the opportunity’s real
And it might last for more than a year.
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 used vacation time to do two short assignments in Petersburg, Alaska. I left the Community Health Center this month because of a troubled Electronic Medical Record (EMR) system.
Having fewer time constraints means more leisurely travel.
Today I slept in till 0730, took my time at breakfast, talked with recruiters, did laundry, packed, and left for Iowa City about noon.
I told the recruiters my ideal job situation: a hospitalist position in Alaska, working alternating weeks, and avoiding the ICU. One recruiter chuckled appropriately, noting that few hospitals exist in Alaska, and perhaps I’d be interested in a similar position in Maine?
Another talked about getting me into a hospitalist position in Gallup. I said, Dine bizaad shilth bahozin ndi doo hozhoo da, and immediately translated, “I speak Navajo but not well.” And a wave of Navajo memories came flooding back. The recruiter expressed amazement, and we agreed such linguistic skill would be a good marketing point. The spot pays 60% of what most hospital positions pay. Still, I think about it seriously.
Maybe, I said to both, but right now I’m waiting to hear back from a recruiter working on a spot close to my ideal, but 4 highway hours from my house, and let’s get in touch on Thursday.
The morning’s email also held an offer for a position in the Alaska interior. They want a 3 month commitment, but the job has appeared over and over in the last two years, and I suspect they might be able to flex if I offered them, say, 18 continuous days on, then 7 continuous days off, enough time to fly home. I slid the email into my Locum Tenens folder.
I munched sunflower seeds and high-quality chocolates all the way to Iowa City. I talked to two more recruiters on the way. I confirmed my ideal situation, discussed where I can flex and where I can’t. One told me about a spot that has gone empty for quite a while, a six-hour drive from home. Can’t fly there? She asked. Nope, I replied, one can only fly from Sioux City to Chicago.
After an uneventful drive, over curry and naan and saag paneer in Iowa City I got to recount some Alaska experiences and the surrealism of Adak Island.
When I checked my email this evening I found a different agency offering the same position 4 hours from home I’d said yes to, and right under that an email from the recruiter I had spoken with. They just wanted you for Thanksgiving week, he said. And I faced a conundrum.
On a moral basis, I owed the first recruiter my business, but the second outfit looks a lot more professional than the first. So I replied to the first recruiter that another agency had offered me that spot, too, and not for just a short-term, and should I go ahead and have them present me for the longer term?
I’ll hear back tomorrow.

Scenes from a convention

I came to get learning specific

In San Diego, out by the Pacific.

I took lots of notes

and paraphrased quotes

But the coincidences were really terrific.

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 to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska and an educational trip to the AAFP Scientific Assembly in San Diego.

I walk into the San Diego Convention Center, my third time here for the American Academy of Family Practice Annual Scientific Assembly.  It still smells like San Diego, the ocean, the palms, the sea.  I stride from one end of the Center to the other, counting the steps and making note of the time, further than my commute from my cottage to the Medical Center in Petersburg, Alaska.

I have the handouts in my backpack.  In years past the book swelled from a couple of hundred pages to two thick binders.  Now they exist on a simple thumb drive.  The same backpack carries my iPad and its associated keyboard.  Last time I came I used a smaller keyboard and my Palm to take notes.  Light and easy to carry, it could beam but not email data.

Now instead of a cell phone I have a smart phone, and I download an app that gives me the course listings with times and places and lets me enter my CME (continuing medical education) credits as they happen.  When I first came to the AAFP convention the words smart phone, Wi-Fi, download, and app did not exist; wireless meant radio, usually two-way, in stodgy British, and the word router denoted an electric wood-working tool.  If you said high-speed net service you might have been laughed at but if you used the term repeatedly you would probably get locked up.

The Exhibition Hall stretches for a cavernous quarter mile inside the Convention Center.  Big Pharma, now barred by law from giving out toys, flashlights, pens, or note pads as advertising, concentrates on pitching drugs.  My Community Health Center patients, half of whom have no resources and no money, can’t afford the new drugs.  But I stop at the Lilly booth and thank the reps for their company’s generosity; they give my facility an enormous quantity of insulin for free.

The lecture on smoking cessation strategies features lackluster content and a passionless presenter.  My attention wanders, I yawn, I try to keep myself awake doing carpal tunnel stretches.  I nod off, then I fire up my iPad and read my email.  I look around and see other attendees either with eyes closed or with their faces illuminated by their portable screens.  No one pays attention.  Five minutes from the end of class I pull out my Droid to try to enter my CME credits, and find I can’t do it without a major workaround.

Even if Big Pharma can’t give us advertising freebies, they can serve us fantastic meals and hire gifted teachers to lecture us.  While I munch an outsized turkey sandwich I marvel at the teaching effectiveness of an FP from Pennsylvania.  She speaks with dynamics and enthusiasm and imparts information I’ll retain after the drug comes off patent.  Except she never mentions a new drug or even an old drug; she talks about urine sugar reabsorbtion and diabetes.

Bethany and I sit down to lunch the next day with a young doc in the Indian Health Service; she nurses her infant while we talk.  At the end I challenge her to keep track of her hours for two weeks, use that number to figure out how much she’s getting per hour and compare that rate to locum tenens.

I run into a doc I knew in residency; I run into him six times more in the course of four days.  Then I run into a doc who now teaches in that program.  In the hotel elevator I run into two more FPs who finished the program and still work in Casper.

One evening Bethany and I dine with a doctor who still works at the Practice Formerly Known As Mine.  At the end of the meal we stroll along the marina.  We come to the Vibrant Curiosity, the world’s 60^th largest yacht.  We had seen the 5 story wonder coming up Wrangell Narrows while we were in Petersburg.  We make jokes about how the owner must be following us and the next thing you know it will come cruising up Perry Creek.

True coincidence occurs but rarely.  But I don’t know what it all means.

Job offers and Sisyphus

Call brings me no compensation

I struggle with documentation

I might sound like a boor

But our EMR’s poor

And a source of great irritation.

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.

 I’m starting to get wanderlust again.

Most days bring 6 to 10 job offers, some permanent, most locum tenens (temporary or substitute).  I look at locations and I fantasize.

Places interest me.  A spot in Wyoming evidently has terrible problems recruiting, I’ve received very good offers for the last 10 months.  Indian Health Service has a trouble filling positions as well.  Veterans’ Administration, Armed Forces posts, and Bureau of Prisons chronically seek physicians. 

The one that piqued my interest the most this week was Nome, Alaska, partly because I just finished Michener’s Alaska and partly because I worked in Barrow.  I wouldn’t really take the job because they want Family Practice with Obstetrics, and I swore off delivering babies on May 7, 2010.  Nor do I want to work more than 2 air hours from surgical backup.  Still it looked like a really, really interesting gig.

Ireland keeps sending me information about “hot jobs.” 

I have no interest in cities, not even exotic cities like Albuquerque or San Francisco, though I might consider something in the Denver area because of family and friends there.  For some reason Wisconsin has fallen completely off my radar screen.

I don’t much look for pay rates; still I’m impressed by some of the figures I see.  Bottom lines upwards of $300K come occasionally, but what really catches my attention are the offers of extra money for taking call. 

Bethany and I had such a great time in Alaska in the winter and New Zealand in the fall. 

While I can still remember the absolute euphoria of coming home and seeing familiar faces and sleeping in our own bed, I can feel myself starting to find fault with my current job.  I have begun to dwell on the call for which I receive no compensation and the hours of documentation I do outside of work hours.  The electronic medical record system (EMR), horribly inefficient to start with, irritates me more and more every day.

And if I miss too much sleep I find judgmentalism creeping into my thoughts.  Hospitalizing the same people for the same problems (which come down to bad lifestyle choices) makes me feel like Sisyphus. 

Yet I really enjoy my coworkers, the morale of the clinical staff runs consistently high, and I like doing hospital work.  A lot of docs don’t.  Thus electronic and regular mail recruiting touts “all outpatient” in capitals with several exclamation points at the top of the page.

The clear ability to walk away from a job gives me tremendous negotiating strength.

Unlike Sisyphus, who had been condemned to eternally roll a boulder up a hill, only to have it roll down just before it reached the top.

Discharge summaries

The patient’s in-hospital chart,

I’ll finish right now, if I’m smart

The time I can ration

To complete the dictation,

To describe the finish and start.

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 48 hours a week.

Completion of a hospital medical record demands a discharge summary.  Nobody ever showed us what a good discharge summary looked like in med school.  We learned from examples, mostly bad.

Med student discharge summaries didn’t count.  In residency I went for thorough at the expense of brevity.  I regurgitated the history and physical, admitting lab and x-ray results, admitting diagnosis, hospital course, and discharge planning in excruciating and unnecessary detail, going through the layers of paper chart day by day. Sometimes the discharge summary went to three pages, single spaced. 

In the Indian Health Service I had to cut back on my words.  However intelligent and hardworking a transcriptionist might be, lack of training in medical terminology made for a lot of errors to correct to finish the product.  Just as well; when I took to typing out my own discharge summaries I pared down the turgid phraseology and left out a lot of irrelevant numbers.  The documents became more useful.

Medical chart completion ranked low on my priorities for most of the time I spent in private practice.  I found motivation only in the periodic letters I got from Medical Records telling me I’d be suspended from the staff if I didn’t finish my charts.

Through my career the grace period, from the day of discharge to the date of suspension, has shrunk from a year in the 70’s to six months in the 80’s, and has now remained at a well-enforced 90 days for the last 15 years. 

But the pace of medicine keeps accelerating.  We strive to follow the patient less than a week after discharge, and the follow-up doc usually didn’t see the patient in the hospital.  The discharge summary becomes less of a formality and more of a necessary and useful document.  I usually dictate the summary at the time of discharge, standing in the hallway.

My format has changed.  A line or two for the story of why the patient came to the hospital, a paragraph each for relevant past medical/personal/family/social history and abnormal physical findings.  A paragraph for lab and x-ray, followed by a paragraph for hospital course, discharge medications plans, and final diagnosis. 

Even at that, a long, a complicated hospitalization (one recently lasted 29 days)can give rise to a two-page discharge summary, but most take a page or less.

In that short space, the necessary confines for a useful document, I can give the facts but not the meaning.  I don’t get to use phrases like self-defeating behavior or inadequate reality testing or stinkin’ thinkin’ or self-imposed social isolation.  If I dictate patient refused counseling, I don’t get to go into the nitty-gritty of why.

The hardest discharge summaries end with “The patient continued to deteriorate and died on…”  Such a stock phrase gives a hollow echo of the drama and irony playing out the final act on the hospital stage, but such phrases I use on a regular basis.  And every time, I can’t help but pause.  The patient gets a moment of silence from me, whether I intend to or not. 

The transcriptionist, I am sure, hears in my voice how my world diminishes with every patient’s death.

Two patients in forty-eight hours with the same unusual eye problem

On the white of the eye, a small bump

Surrounded by vessels so plump

     I don’t know why

     It shows up in the eye,

When the infection is down by the rump.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  Right now I’m living in Amberley, and seeing patients in Waikari, in New Zealand’s South Island, an hour outside of Christchurch.

Twice in the last forty-eight hours I’ve seen patients with the same unusual eye problem.

Both had irritation of the eye and a little bit of discharge, neither could tell me the color.  When I looked closely at the sclera (the white part of the eye), I saw a white lump the size of a caraway seed, surrounded by inflamed blood vessels. 

“That little lump,” I said in both cases, “Is a phlyctenule.”

I didn’t learn about phlyctenular keratoconjunctivitis(PKC) in med school or residency but in the Indian Health Service, when I took the IHS tuberculosis course.

I have not seen a good explanation of PKC, where an infection somewhere else in the body triggers an allergic reaction in the eye.  In the IHS we maintained a protocol that included a TB skin test and a chest x-ray.

I haven’t seen a case of PKC triggered by TB since I left the Indian Health Service; in the absence of respiratory symptoms or a history of probable exposure I don’t check a chest x-ray.  I ask about other infections, especially skin, and especially fungus.  Usually I don’t get anything to go on and I end up giving the patient an anti-inflammatory eye drop.

Both patients with PKC turned out to have other infections, and in the process of explaining and asking, I uncovered drama, irony and surprising facets of human love.

I don’t see all that many phlyctenules since I no longer work for the Indian Health Service and sometimes I’ll go years without seeing one.  Most docs don’t recognize the abbreviation PKC, but the charge sheet we used in New Mexico listed it on the menu of 50 most common diagnoses.

Outside of contact lenses, most non-traumatic eye problems have to do with infections.  The majority of patients with the red, runny mattering that signals pinkeye have conjunctivitis, mostly viral.  The ones with bacterial infections need antibiotics.  Viruses outside the herpes family clear without treatment; herpes I, herpes II, or the chickenpox/shingles virus in the eye constitute a true eye emergency, requiring a specialist.

Eye infections that keep coming back, I explained to one of the patients, usually respond better to baby shampoo and Q-tips than to antibiotics.  The follicles of the eyelashes become clogged with debris related to the eight-legged crustacean called the human eye mite, and detergent action cuts down on the infestation.

Why I do and I don’t do housecalls

The number of docs is deficient

Though the need would appear quite sufficient

    If you ask me why is it?

    I’ll say a home visit

In the end remains inefficient.

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.  I just got back from a six-week assignment in Barrow, Alaska, the northernmost point in the country.

My father made house calls.

He graduated from medical school sixty years ago, when women were systematically excluded from the profession.  At that time, a physician finished an internship, hung out a shingle, worked solo practice, and took call 24/7/365. He made hospital rounds in the morning, saw patients through the day, and, after supper, made evening rounds and house calls.

Our 1960 Ford Falcon had a spotlight, like the police used, so he could see house numbers at night.

He used to take me with him, to the hospital and to patients’ homes, when I was in elementary school.  I waited in the front lobby of the hospital at a time when it constituted the main ingress, but I got to go into houses with him.  I remember the time spent with him, I don’t remember the time spent waiting.  I can see his stethoscope hanging by the front door, his electrocardiogram machine in the back seat, and his doctor’s bag with the blood pressure cuff and medications like Demerol , penicillin, and digitalis.

But in an era of generalists, my father specialized first in Internal Medicine, and then in Cardiology.  ICUs and CCUs didn’t exist, and before revascularization, statins, and beta blockers, patients with heart attacks frequently received treatment at home.  Looking back, hospital care at the time differed little from a doctor making a home visit.

I have done house calls, but I probably don’t do more than twenty a year. 

When I worked for the Indian Health Service in New Mexico, the government tore down a perfectly functional clinic and paid me to do nothing until the new clinic was built.  After two weeks I realized I had started to be mean to my kids and I hijacked the Community Health Nurse to take me on hogan visits.  I learned a lot about my patients I wouldn’t have otherwise known.

Mostly, when I care for a patient in the home now, I do so more for my convenience than for the patient’s. 

Once, when a heavy, wet snow closed the city and the clinic down in the middle of the day, I got a page from a patient with bad lungs, heart, and balance just as I was about to exit the building.  In the days before common use of cell phones, I turned around, shucked off my parka, and returned the call.  After a brief conversation, I knew I lacked certain key items of information from the physical exam to make a good clinical decision, and I didn’t want to endanger the patient by making him go to the ER in bad weather.  I asked the address, and saw that the patient resided between my clinic and my home. 

I arrived fifteen minutes later on roads I could only negotiate with four-wheel drive.  Fifteen minutes after that I asked for a towel as I washed my hands at the kitchen sink, grateful for the warmth of the water and a ritualized end to the visit.

Today, I talked with a friend and patient who lamented the absence of my house calls.  We talked about how inefficient such delivery of care is, and how we don’t have enough doctors to make the service available on a regular basis.

It’s rare that I do house calls now.  Documentation suffers the longer one waits to make one’s note.  Still, I have a dedicated stethoscope and otoscope in my car.

But I don’t carry a black bag with Demerol, digitalis, or penicillin.

Cocaine, nosebleeds, and snakebites: lessons learned in a hurry and not forgotten.

Is cocaine the thing that you need,

When it comes to a nose that would bleed?

     Would some other med

    Do the same job instead?

It depends on the books that you read.

I did my residency in Wyoming.  Thirty years ago, I had a license and when I had a free weekend I could work where doctors needed help.  Most places paid fifteen dollars an hour; a seventy-two hour weekend could generate a lot of cash for a young man who had just finished twenty-one years of student poverty.  I soon found that the value of the learning experience exceeded the importance of the money.

In a large state with very few people, before the Internet, I found the pressure of dealing with medical problems outside my experience stimulated me to read, learn, and retain. 

Once, the ER where I was moonlighting got a call about a person who’d been bitten by a snake and would arrive within five minutes.  I had never seen a case of snakebite, but I went to the bookshelf, pulled down Rosen’s two volume Emergency Medicine, and read as fast as I could.  I looked up; no patient, but I had another minute before arrival.  I pulled down Harrison’s Principles of Internal Medicine and read what it had to say about snakebite.  The patient now three minutes late, I took a breath and started plowing through the books at hand.  Twenty minutes later, amazed at how much I’d learned in so short a time, I went to lunch.  The patient never arrived.

When confronted with a frightening nosebleed, Emergency Medicine provided me with a chapter that shines as a paragon of what medical writing should be: a review of the anatomy and physiology, elements of history and physical, proven techniques, and pitfalls, in a concise ten pages.

I faced an epidemic of nosebleeds at the Indian Health Service hospital where I worked fresh out of residency.  I could never determine if my hospital alone or if the area IHS hospitals in general had had their supplies of cocaine removed, nor for what reason.  I knew, for sure, that when I was confronted with the only legitimate use of the medication, nosebleeds, or epistaxis, I couldn’t get my hands on the drug of choice. 

We made do with 2% Lidocaine with epinephrine.  For a year and a half I saw a minimum of two major nosebleeds a week.  Most were the common variety, where the bleeding comes from the front part of the nose, but we also saw the terrifying bleeding from the back part of the nose.  I remember calling up the consultant in the big city at the other end of the highway and saying, “The patient has my best anterior (front) and posterior (back) nose packing job and he’s still bleeding, I’m afraid you’re going to end up ligating (tying off) his external carotid artery.”

“Nah,” he replied, “I haven’t had to do that for ten years.”

He called me the next day and said, “I had to tie off the external carotid.”

My experience with nose bleeds has stood me in good stead ever since, and yesterday I took care of two patients with that problem.  For one, I simply pinched the soft part of the nose shut for five minutes, and the bleeding stopped.  When I looked at the middle part of the nose, I found diffuse redness. 

The dry air in Barrow gets worse in the winter, and noses desiccate and bleed; most of those patients don’t need anything more than a little bit of Vaseline a couple of times a day.

When I looked at the other patient I found a snake-like varicose vein, the origin of the bleeding, about the length of an eyelash.  Numbing the area the way I’d learned in New Mexico, I touched bleeder with a silver nitrate stick for three seconds.  The nitric acid from the stick created a burn, and the vein stopped functioning as a blood vessel. It won’t bleed again.

It hurt like the dickens.  The Lidocaine hadn’t done its job as anesthetic, not like cocaine.