Whales, eagles, and salmon

The fish will never ask why

Their biology demands that they try

The end couldn’t be sadder

For at the end of the ladder

The salmon spawn and inevitably die

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 taking a working vacation now in Petersburg, Alaska.

Life in Barrow, Alaska finds the rhythm of its heartbeat with the whale, Keosauqua with the deer.  Our home town of Sioux City, Iowa breathes with the corn cycle.  Petersburg, Alaska has its pulse with the fish, in particular, the salmon.

A Norwegian fisherman opened a cannery and founded the town about a century ago, and Petersburg has depended on salmon since.  They also catch cod, crab, shrimp, and halibut, but without salmon, the town wouldn’t exist.

Nine hundred seasonal workers came this summer to work 16 hour days in the canneries, and you can find no more than two degrees of separation between anyone in town and the fishing industry.  By the time someone finishes high school here, they have worked in that industry at some level, whether on a fishing boat or in the cannery.

Today we drove out to Hungry Point and watched the same humpback whales we’d seen in Maui.  We had brilliant conversation with two tourists from Australia.  We went a bit further down the coast to Sandy Beach and watched pink salmon desperately trying to swim upstream to spawn and eagles leisurely waiting to feed on them.

We enjoyed the spectacle, and talked to some people from Petersburg.  The rainfall ran short this summer, and the beautiful clear days have come at a price; one can’t have a rain forest without rain.  Streams have to have adequate flow for the salmon to swim.

People who live here will readily say that king, or Chinook salmon taste best, followed by red (sockeye) or silver (coho).  They speak with disdain of the pink (humpies), saying they’re good for cat food.  And no one even mentions the chum or dog salmon in terms of human food.  Yet the canneries this year will mostly process the pink salmon.

We drove out south on Mitkof Highway along the Wrangell Narrows.  We found the fish hatchery closed, and by then the good hard rain made viewing salmon swimming impossible.  On the way back to town we stopped at the Falls Creek fish ladder, which we found despite the abysmal signage.  While the rain came harder and harder we stood and looked over the concrete, manmade steps that parallel the roaring rapids.

It took a while till we knew what to look for, then the drama of the eternal struggle of life’s longing for itself played out in front of us, salmon desperately swimming against an overwhelming current to find a place to lay and fertilize eggs before they die.

No Pacific salmon survives the reproductive process.

Two beepers, three phones: first night on call in Amberley

These days, the bag isn’t black,

Not one, they are four, each a pack.

      You can’t carry them far

     Unless you’ve a car

And for beepers there’s never a lack 

Synopsis: I’m a family practitioner from Sioux City, Iowa.  On sabbatical to dance from the brink of 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 on assignment in Waikari, a rural area in New Zealand’s North Island, an hour outside of Christchurch.

I took my first night on call. As I left the clinic in Waikari the nurse handed me four backpacks of medical equipment: one each with oxygen, resuscitation equipment, resuscitation medications, and immobilization devices like cervical collars.
My father, a physician, carried a black bag everywhere, even on vacation, and we, the children, couldn’t understand why he would do such a thing. I understand why now, and with greater understanding comes an adult’s disagreement.  A vacation needs to be a vacation, a time to rest and let go of vigilance.

An article 105 years ago in the Journal of the American Medical Association detailed what a doctor should carry so that lives could be saved outside of hospital.

The black bag has morphed into the 21st century in New Zealand.  The internal combustion engine assures the doctor that a hundred pounds of gear stays available. What would have passed for dead on the spot a hundred years ago has become salvageable.
In the US, doctors don’t get on-site trauma training. Few would go to the scene of an accident or tragedy.  Almost none make house calls, and the black bag remains a relic of the past.

Here, an on call doctor might respond to the site of a cardiac arrest or massive trauma car collision.

I made a house call in New Zealand for a post-op Maori patient.  Manicured grounds surrounded a well-maintained home down a long driveway.  (Most Kiwis take better care of their yards most Americans, and the homes, for the most part, are neater.)  I brought a stethoscope, but all I needed was good clinical judgement and compassion.

I arrived home today with two beepers clipped to my belt, one for each geographic district that I covered, and the clinic cell phone in addition to my NZ cell phone (still undependable) along with my American Droid. 

I haven’t carried a beeper for a year.  In Alaska the hospital provided a wonderfully reliable cell phone; in Keosauqua my cell phone coupled with my apartment land line served well.  With no call in Grand Island, I didn’t need any sort of after-hours communication. 

Yet I clipped the two hip-sucking parasites on my belt, and, as if they had never left, they felt right at home.  I shuddered.

With my five pieces of electronics and Bethany’s two, we went out to supper, and just as we walked up to the restaurant, my clinic cell phone rang.

I gave instruction about stopping bleeding from a cut that didn’t require stitches. 

I have discovered that the secret for sleeping well when on call consists of convincing yourself you’re not on call.  I looked at my quintuple-redundancy electronics and lied to myself, but I still had a faint niggle at the back of my mind.  Self-deception prevailed for six hours of sound sleep but not for all eight.  I received no calls.

I gave over the beepers in the morning, and as soon as I got to the clinic I gave up the extra cell phone.

A seven-week road trip in review

As I welcome in the New Year

Let me make this perfectly clear,

     For this I can vouch:

     I sleep well on a couch.

Watch out for eagles and deer.

I am back in Sioux City after a six-thousand mile, seven-week road trip.  I stopped to visit family in Chicago, New York, Long Island, West Virginia and Virginia.  I saw friends in Iowa City, Pittsburgh, and Columbus, Indiana.  I worked for a month in Keosauqua, in southeast Iowa.  I took the Advanced Trauma Life Support course in South Bend, Indiana.  I relived memories in Illinois and Indiana.  I feasted Thanksgiving in Virginia with Bethany’s family.

Even outside of work, I gave advice about rashes, ears, coughs, nutrition, exercise, bipolar disease, depression, sleep, smoking cessation, alcoholism, sex, and plantar fasciitis.  I helped assemble Ikea furniture and I took stitches out of a dog’s leg.

I hunted deer in Iowa and I didn’t hunt deer in Virginia.

I discovered I like sleeping on a friend’s couch more than I like sleeping in a nice hotel, and that some sofas are more comfortable than some beds.

I ate out a lot.  Portion size nowadays suffices one person for two meals.  Chinese food varies a lot from restaurant to restaurant, which adds to its charm. 

I found out I drive long distances better at night than during the day, and that I never, ever want to drive in New York City again. 

I learned to recognize signs of psychosis in Sweetheart, my GPS.

I saw lots of deer and foxes (living and dead), llamas (all alive), migrating ducks and geese, a few grazing buffalo, dozens of soaring vultures, a piliated woodpecker, and a surprising number of eagles.

I worked in Keosauqua, Iowa, for a month and had a wonderful time; few things bring me as much pleasure as curing a person before they leave.  I like living close enough to work that I can walk; I love working with good colleagues.

Revisiting the routes I travelled when I hitchhiked in the sixties and seventies showed me that the road changes slower than society.   I found more prosperity now than I did then; I saw no hitchhikers anywhere.

Some people figure out things out with time, some people don’t.  A lot of people from my past turned out to be bipolar.  Drama and irony dance with the human condition; even orderly communities wrestle with grief.

Money doesn’t buy happiness but a good night’s sleep comes close.

The number of wind turbines I saw from the highway indicates our country’s energy policy shift towards the renewable.

I get better gas mileage and I see more things to write about when I drive 55 than when I drive 75.

I had a great time everywhere I went, but I like home the best.  I missed my friends, my wife, my house, my kitchen, and my bed. 

I make friends easily but I missed the friends I’ve had the longest.

I missed my social network.

I like geology.  I enjoyed looking at the exposed history of the earth in road cuts.

I missed cooking so much that when Bethany took a weekend and visited me in Keosauqua I cooked beef bourguignon. 

I missed speaking Spanish.

They say you can’t discover new lands if you never lose sight of the shore; I don’t think you can learn how much you love home if you never leave.

After thirty years, a case of Reiter’s syndrome, and my last Keosauqua patient shatters my complacence.

When I stopped to check out the heart,

The rhythm gave me a start.

     It was going too fast,

     And that patient, the last,

Went out on the ambulance cart.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year non-compete clause ticks off, I’m having adventures, working, and visiting friends and relatives.  I’ve been on assignment in Keosauqua, in southeast Iowa.

Today I finished my last clinical day in Keosauqua.  The first patient of the day and the last patient of the day each gave their permission to write the information below.

Reiter’s Syndrome includes the triad of conjunctivitis (inflammation of the eye membranes), urethritis (inflammation of the lower urinary tract), and synovitis (joint inflammation).  Such a constellation signals the body’s abrupt inappropriate reaction to an infection; while attacking germs, the defense mechanisms start to attack the person’s own tissues. 

Separately, each of these three items comes as common as rain, and for the last thirty years I’ve asked each patient with one of them about the other two.  I also ask about fever and rash.  The interview sequence qualified long ago as low-yield, but I persisted for sake of thoroughness, and, later, from habit. 

Over the years, my interview technique has evolved.  In the beginning I listen, later on I ask focused questions.  Today, when I said to the patient, “Tell me more,” three sentences in quick succession revealed knee pain, discharge from the eye, and discharge from the penis.

For the first time, ever, today I made the diagnosis of Reiter’s Syndrome.  I started the proper lab investigation and turned the case over to a colleague.

For those interested in medical history, Christopher Columbus suffered from Reiter’s Syndrome on his last voyage.

The last patient of the day came in with a routine complaint of cough, also a frequent problem in temperate climates in the winter.  Such symptoms have been going around Van Buren County during my short stay here, and I anticipated ending my tenure routinely.

The human condition tends towards complacence.  We tend to “know” we’ll find a normal cardiac exam singing “lub-dub, lub-dub.”  If those sounds don’t come through the stethoscope, the brain tends to want to make the perceived sound fit into the expected sound.

Today it didn’t.  “Breathe normally,” I told the patient, and tried to hear the heart sounds over the abnormal breath sounds.  Unsuccessful, I said, “Hold your breath.”  The first and second heart sounds refused to distinguish themselves; the first kept shifting in timing and character.  And the rate came way too fast.

I took my stethoscope off and checked the pulse, which came through nice and regular.  I listened to the heart again.  The chaotic rhythm pounded irregularly irregular. 

The reassurance I sought from the electrocardiogram fled before my eyes.  Yet the patient had no heart symptoms at all; no chest pain or sensation of his heart racing.

I grabbed one of my colleagues and showed him the strip.  In short order we had sent the patient off in an ambulance.

We agreed that the weird stuff is out there.

Art and Architecture in rural Iowa: Bethany and I do American Gothic

There once was an artist, Grant Wood,

Who did that best that he could

    A house he did paint,

    With a couple so quaint

And the parodies all turn out good.

Bethany drove six hours from Sioux City this weekend, and yesterday I took her for a walk around town.  We heard a skittering cry from a large bird gliding above the Des Moines River.  We stood still to watch, it circled and wheeled and leisurely came to us, twenty feet up, a bald eagle, with snow-white head and tail.

Then we heard the helicopter. 

The sound of a helicopter in a small town usually bodes ill as the harbinger of significant injury or illness.  We strode up the hill to the hospital.

My colleague had the situation well under control.

We walked past the Manning Hotel, an historic structure dating to the era when goods moved by riverboat and horse. 

The Manning Hotel, Keosauqua, Iowa, on the banks of Des Moines River

The bridge over the Des Moines River here carries partitions for three types of traffic: the east lane for pedestrians, the center lanes for cars, and the west lane for horse-and-buggy (the Amish regularly cross the bridge).

This part of Iowa has wonderful architecture, with colonnaded porticoes and functional verandas on many houses.  Victorian-style gingerbread sits next to single- and double-wide trailers.  In Birmingham we found a trailer with a colonnaded portico.

Trailer with collonaded portico

On the way there we saw the sign proclaiming AMERICAN GOTHIC HOUSE 18 MILES.  Today, we made the drive.

Grant Wood’s painting, American Gothic, ranks second only to the Mona Lisa for number of parodies.  The house, I have been told, is the second most recognizable house in the country, after the White House.

That house still stands at the edge of Eldon, Iowa, less than a half hour from Keosauqua. 

The town itself looks like many other small towns but for the beautiful architecture.

The American Gothic House reminded us of the size of our first house in Casper, Wyoming, with less than nine hundred square feet.  The American Gothic House Center, on the other hand, stood large in the neighborhood, with a CLOSED sign in the front door.

Bethany at the American Gothic House Center. Eldon, Iowa. December 2010

Of course we had to make our own parody of Grant Wood’s famous painting, which rendered difficult the task of trying to look dour.  I had not a pitchfork nor a shovel to hold, Bethany observed, as she shivered and tried not to crack a smile. 

Steve and Bethany in front of the American Gothic house, Eldon, Iowa, December 19 2010

With the camera screwed onto the tripod, the self-timer did its job as hypothermia started to set in.

The famous house now shares the corner with a single-wide trailer; functioning agricultural buildings stand between it and the corn fields.  A trendy compact car nestles in back.

The American Gothic House and Mini-Cooper, Eldon, Iowa, Dec 19 2010

The recognizable icon stands but the times, as always, change.

Santa at the library. Warning: humorous content

The problems of running a sleigh!

With six months of night and of day,

     To deliver a toy

     Or in Hawaii, some poi,

I don’t send the elves out to play.

Synopsis:  I’m a family practitioner from Sioux City, Iowa, transitioning my career.  While my one-year non-compete clause ticks out I’m doing locum tenens work, and having adventures.  Currently I’m in southeast Iowa.  I played Santa this week, and my sense of humor broke loose.

I put on a red suit and went to the Keosauqua Public Library as Santa.

I talked with one of the librarians after the rush of kids slowed down.

He commented he hadn’t seen my sleigh.

“It’s second shotgun season,” I said.  “You know, I was crossing the Van Buren County line just before dark, keeping the sleigh low along the river over there by Bonaparte, I heard a shot and I’m darned if a 12-gauge slug didn’t crease Donner’s left hind hoof.  Scared the heck out of me.  I took her up about two hundred feet, swung south there and crossed into Missouri, set her down in an alfalfa field to check out the damage, wouldn’t you know up drove a guy, a doc, in a ’98 Toyota Avalon.  We yacked a little bit, he said he’d do what he could for Donner even if he weren’t a vet, and let me drive his car into town.  That’s why I came in late.”

The librarian nodded.

“Heck of a deal,” I said, “You know at the North Pole we get six months of daylight to make all those toys but when the sun goes down on September 22, it goes down and it stays down, and I’ll tell you what, it gets dark.  And we just keep working through the winter solstice, it gets to be December 24^th and I head south, I cover a lot of ground.  You know, I remember back winter of ’93 when we had all that snow, I was fixing to land on the roof of a farmhouse outside of Effingham, Illinois.  Well, they hadn’t shoveled the snow off the roof and wouldn’t you know, the thing caved in and I put the sleigh down in the farmyard about the time the family came running out of the house. Everyone was OK and I gave out the presents one on one and when I turned back to get in the sleigh, well, you know how the Santa’s breed of reindeer makes AGH?”

He furrowed his forehead at me. 

“Anti-Gravity Hormone,” I said.  “Well, those animals got awful hungry with the cold and the snow and all and they smelled some of those apples still at the top of the apple trees there around the farmyard and, well, you just can’t trust those reindeer with your back turned.  Except maybe Prancer, and even him…

“So I turned around and those reindeer were browsing on the twigs at the top of the tree, getting the mummy apples, they were going at it pretty good and wouldn’t you know I had to borrow a ladder to get back in the sleigh, and climbing that thing isn’t easy when you’re as short and fat as I am, it’s not like you can just put your finger on one side of your nose and whoosh you’re up like you can in a chimney. 

“That was the year I got a letter from a fellow in the jail in Lame Deer, Montana, on the Northern Cheyenne reservation.  What he wanted, see, what he wanted was lithium.  I had checked my list on this guy, twice, and I can tell you he hadn’t been good.  Really, pretty naughty.  But I looked at what he wanted, and, you know, I figured, lithium.  You know, why not.  Ever since then someone asks for lithium, I don’t even check the list, I just figure I’ll make the stop.  And it’s a simple package, doesn’t weigh much, not like those cotton-pickin’ ponies.  Doesn’t take hardly any elf labor.

“Me and the reindeer we get back from a run and we’re really, really tired.  So are the elves, so is Mrs. Claus.  But we get the animals out of the harness, and even if the elves are getting sleepy I get ‘em to hang up the harness, we don’t use saddle soap anymore…”

“No?” he asked

“No, we went to all-Kevlar harness, oh, heck, it’s got to be twenty-five years ago.  Just saves one more step when I bring in the sleigh.  Takes twenty-four elves to curry-comb the reindeer and they’re getting a little edgy at that point in the season.  If they haven’t mucked out the reindeer stables, well, I got to get on ‘em about that, oh, I’d say three years out of four.  But me?  I’m the one that feeds ‘em.  You know, we got some really first class hay out of Montana last year, good clean alfalfa.  Not like that, you know, Santa shouldn’t use such language, so I’ll just say stuff with a capital SH that we were getting out of Siberia.  Tell you what, don’t sign a contract with a Chechen.  I should have known better than to deal with a company’s got everyone on the naughty list.

“By the time the reindeer are taken care of and stabled, we sit down to darned fine meal.  You know those dry does in the reindeer herd, I’ll tell you what we eat pretty darn good.  Then we go take a nap.  Now, remember it’s the Arctic night, and we just snooze for a couple of months.  When we get up Mrs. Claus keeps making breakfast, coffee, doughnuts, reindeer salami and cold storage eggs, till the sun comes up on March 23, and then we’re back at it.  Magic reindeer drop their antlers when the sun comes up like that, that’s when they stop making AGH and they don’t fly till they’ve scraped their velvet.

“Then you gotta watch out.   Rutting deer are bad enough, but when the flying reindeer go at it, it’s dangerous for the aircraft.  We took to tethering ‘em just before they take off.

“But there was one year, ’01, Vixen was still in velvet and I had a bad run of Barbies in the shop…”

He raised an eyebrow.

“Yeah, you know, the Somali elves had just come on board and they didn’t know metric from English, and if you think Barbie’s proportions were unrealistic, that run was just plain science fiction.  Anyway I just didn’t send the elves out to tether ‘em quick enough and before you knew it, Vixen was off.  You know how those polar air currents are.  Well, he went chasing the does outside of Atqisut Pass.  I had to harness up an empty sleigh to go looking for him, and he was darned hard to catch when I got there.   Good for me he was closing in on a bunch of estrus females when some Inuit opened fire and he lit out of there just as we were flying in.

“That’s the year I put GPS tracking onto their collars.”

Dear Readers:  This is my first attempt at a humorous post.  Please let me know what you think.

An imposter impersonates impersonators impersonating an impersonator

In the evening I had a short pause

Why did I do it?  Because.

     I suppose I look cute

     In the funny red suit

An imposter of old Santa Claus.

As a doctor, people frequently ask me to do things that have nothing to do with medicine.

I worked with the Canoncito Band of Navajo early in my career.  Shortly after Christmas in 1984 a patient brought in a digital watch and asked me to set it for her; the conversation took place in Navajo.  She had an exquisite silver and turquoise watch-holding bracelet she’d placed the timepiece in.  I read the instructions and set the watch as requested, struck by the contrast between the hand-crafted jewelry and the cheap, mass-produced electronics.  The patient couldn’t tell time, and if she could have, time on a watch has no meaning in the Navajo world.

Shortly after I arrived in Keosauqua, I received a call asking me if I’d play Santa Claus at the library.  I’d never done such a thing before, I said, but I’d be willing to as long as I didn’t have to provide the suit.  The outfit, she assured me, would arrive two days before the event, which would go from 4:00PM to 8:00PM, on weekend evening.

Not long after, the date changed to a Wednesday.  No problem, I said, but remember I can’t be there until after clinic, which ends at 5:00 if I’m lucky

At 4:55, the nurse poked her head in to tell me my last patient was ready.

A non-trivial injury required x-rays, which weren’t ready till 5:22.  I explained to the family the importance of the diagnosis and arranged follow-up with a specialist.  In the middle of the explanation my cell phone sounded.  Would Santa be showing up?

Yes, I answered, but I still had patients to take care of.

I didn’t get my hurry hormones going and I didn’t finish my documentation.  I got into the Santa suit as fast as possible and made the three-minute drive to the library.

Santa impersonator outside of the Keosauqua Public Library

 

I don’t celebrate the holiday that Santa represents, and the Vatican de-canonized St. Nicolas. Thus, current Santa suit wearers impersonate impersonators, making me an imposter of an impersonator impersonating an impersonator.

The kids came and sat on my knee, serious in asking for things I’ve never heard of and frequently couldn’t understand.  I looked into faces and diagnosed allergies. I listened to coughs I knew were asthmatic.  I smelled parental smoke on innocent victims.  I found the frequency of speech impediments more shocking that the young materialism.   I spotted two children as adopted. 

Waiting in line to talk to Walkaboutdoc, aka Santa Claus

One blond girl missing two front teeth asked if I were the real Santa Claus.  “What do you think?” I asked.  She couldn’t decide.  I said, “You know, under my fake beard I have a real beard,” and I lifted the false white plumage up to reveal my gray facial foliage.  Her eyes widened.  “You ARE!” she exclaimed.

Mennonites and CT scans

For the patient, here is the plan

Forget the equivocal scan

     I don’t need much urgin’

     To call up the surgeon

With the results of the tests that we ran

SYNOPSIS:  I’m a Family Physician from Sioux City, Iowa, making a career transition to avoid burnout.  While my one-year non-compete clause ticks off I’m traveling, doing locum tenens, and having adventures.  Right now I’m working at Van Buren County Hospital in southeast Iowa, where there are no stop lights or fast food.

I’m on call in Keosauqua, Iowa, where the mid-level providers (Physician’s Assistants and Nurse Practitioners) take first ER call, and the MD or DO provides back-up and more definitive care. 

The day till now has run on a low stress level.  As with any other day I care for patients, I came across a physical finding I’d never seen before, a soft lump where I should find hard bone.  The MRI machine comes in a trailer tomorrow and will give me an answer.

I hesitate more about ordering MRIs now than I did when I owned a part-share in a scanner, but I seem to order the same number.  I’m likely to fill out the paperwork and jump through the insurance company hoops when back pain goes down the leg and doesn’t get better, when mysterious physical findings can’t be denied, or when the patient worsens.  I find a lot of occult fractures, that is, broken bones that didn’t show on x-ray.

I remember patients I sent for MRI when I had profit motive to do so; scans showed problems malignant and benign, and surgeons prolonged or saved lives.

Keosauqua has growing Amish and Mennonite populations.  They call us English even if we aren’t English, we call them Pennsylvania Dutch even if they don’t live in Pennsylvania and they aren’t Dutch.  Their economic basis depends on subsistence farming; their agricultural methods qualify for the trendy buzzword sustainable.  I haven’t seen horse-drawn vehicles on the roads here but I have seen traditionally dressed people at the café and in the hospital waiting room.

A call comes from the ER for me to evaluate a Mennonite patient.  I find the family straightforward, respectful, and friendly.  I’ve seen the problem at hand hundreds of times.  The CT scan, ordered before I saw the patient, comes back equivocal, but my exam makes a firm diagnosis requiring a surgeon.

Our surgeon and I have come to similar places in our careers: we want to work but we want to slow down.  His solution to the full-time-means-eighty-hours problem led him to work two weeks out of four, while I intend to go to a forty-hour week when I get back to Sioux City. 

Thus, the patient arrives while our hospital’s surgeon is en route to Florida.

I admit my surprise when the matriarch pulls a cell phone from her skirt pocket.  You should have been there.  The family requests a surgeon across the state line in Missouri.

I make the call requesting a transfer, speaking to the surgeon herself.  My presentation of the patient comes off smooth and articulate.  

The family drives into the night, subsistence farmers with hard copies of lab results and a CD copy of the CT scan.

Contrast is the essence of meaning.

Blizzards, syphilis, and nosology (the study of how we know what we know)

How do we know what we know?

If the test says ‘yes’, is it so?

     False positive rates

     In some disease states

Can lead to some terrible woe.

 

Cold came to Iowa overnight, strong enough to generate national news.

I arrived to make hospital rounds yesterday, and talked with the doc on call.  We eyed the weather reports and I took over call early, allowing the other physician to get home before a blizzard hit.

Patients like to stay sheltered when the wind chill goes to double negative digits, only the much sicker come in. The forecast called for 40-50 mile per hour winds, heavy snow, and temps around zero.  After supper I packed an overnight bag and returned the half-mile to the hospital.      

I didn’t have to stay the night at the hospital; I could have waited to get called.  I wasn’t sure the blizzard would really happen, but I didn’t want to face whiteout conditions trying to get to the ER. 

I drifted to the nurses’ station first.  With a census of three, the staff outnumbered the patients.  We chatted about the cold, deer season, and the patients.  I got some surprise lab results.

Mostly we get information from laboratory tests to confirm what we think is wrong; rarely (not never) do we generate as much decision making from x-rays or blood and urine tests as we do from talking to the patient.  Sometimes the patient can’t talk, can’t remember, or won’t tell the truth.  In those cases lab and x-ray add heavily to the diagnosis.

Yes, I ask for tests “just to make sure,” and sometimes when the case perplexes me I’ll order a large number of lab tests.  Ninety percent of those results come back as expected.  Ten percent of the time they don’t.

I finished residency thirty-two years ago, when syphilis used to be called the ‘Great Pretender’ because it could mimic any other disease.  As med students we learned to order certain labs as a matter of course, especially the serologic test for syphilis, aka STS, Wasserman test, VDRL, or RPR.  Later we learned to order the confirmatory test, the free treponemal antigen (FTA) or Treponema palladium plasma antigen (TPPA). 

As rates of syphilis fell, the disease changed and enthusiasm for testing waned.  In medical school, we were taught that the infection always started with a sore.  By 1990 the sore happened occasionally.  Now we almost never find one.

I still test for syphilis despite low rates.  Since 1982 on five occasions the test came back positive and surprised us all; on one occasion, years ago in another place, the positive result startled me but not the patient.  I came away with a history lesson in riverboats and an appreciation for Midwestern life in the thirties. 

The diagnosis remains a problem in nosology.  The first test has false positives (as in Lyme disease) and false negatives (late in the illness), the second test has no false positives but cannot distinguish active disease from prior infection.  In the end, there is no substitute for clinical judgement.

Relating to a patient at the end of a long day.

As I came to the end of the day,

I heard my clinic nurse say,

    It’s hard to believe,

    But it’s not time to leave,

One more patient is on the way.

I walked to work this morning. 

I reside a half mile from the hospital, along roads with no sidewalks.  I awoke rested, without an alarm.  I cooked and enjoyed my breakfast, did my morning dishes, and suited up for the cold.  On a day with no wind, a temperature of 8 F didn’t challenge me.  I watched the sunrise over the Des Moines River. 

Sunrise over the Des Moines River, viewed from Keosauqua, December 7, 2010

One of the other doctors and I have decided to discuss patients first thing in the morning.  He talked about his patient from the day before and I went over my chest pain admission from yesterday.  I discharged the patient by 9:00 AM.

The morning went well, mostly adults and children with coughs.  Pertussis, or whooping cough, appeared in the school system last week, but none of the patients showed anything like a typical case.  I told lots of people to quit smoking, and I wrote ALL SMOKE OUTSIDE as a prescription four times. 

I left the clinic area at noon for the cafeteria.   I enjoyed my lunch, I talked to the staff members and received many subtle and not-so-subtle hints that I should move to Keosauqua. 

I had finished with afternoon patients and documentation by 4:30 this afternoon.  While considering whether or not I’d leave early, the nurse told me one more patient, a very complicated one, remained, but wouldn’t arrive for a while yet.

I sat down at the computer, unfazed.  Paid by the hour with no other agenda for the evening except supper and laundry, I had no grounds for annoyance.  If such had come to pass eight months ago, I would have seethed, frustrated that the goal posts had moved, and worried about paying staff overtime.

Tonight, I focused on taking care of the patient. 

I listened to the history without interrupting, then did a thorough exam.  Enough time elapsed during the visit that a critical lab result arrived before the patient left.

Ninety percent of what we know about a patient comes from the story the patient tells, eight percent comes from the examination, and two percent comes from lab, x-ray, CT scans, and ultrasounds.

During the visit I recalled my experience with ankylosing spondylitis.  At age seventeen the back pain started, accompanied by morning stiffness.   Three years later my body temperature dropped to 94.8 F.  I dealt with relentless symptoms for the next thirty years, and in the process acquired a first-hand appreciation for chronic pain, ruthless non-restorative sleep, and fibromyalgia.

I talked to the patient as one who has “been there.” I trust my words brought hope. 

I left the hospital under black, starry skies.   After supper at the restaurant around the corner from the apartment, I returned to do laundry, and I thought about a list of diagnoses that no-one wants to have.  

Ten-hour days reasonably paced beat ten-hour days rushed.