Posts Tagged ‘neurologic exam’

Fisherfolk and forest fires.

July 20, 2017

If you can’t take the fire, stay out of the smoke

The stuff that makes you wheeze, cough and choke

This great conflagration

Caused evacuation

And perhaps even brought on a stroke.

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 finished my most recent assignment in Clarinda on May 18.  Right now I’m in northern British Columbia, getting a first-hand look at the Canadian system. Any identifiable patient information has been included with permission.

I had call this last Friday, Saturday, and Sunday, and I’m on call again tonight, Wednesday. Over the weekend I saw so many people with possible or definite stroke that my neurologic exam, thorough but a bit rusty on Friday, was polished and speedy by Monday morning.

I have had to do suturing at least once a day for the last week. I do not anticipate robots taking over this part of my job in my lifetime; especially if children are involved.

Stitching people up brings the opportunity to just chat with the patient, and I got the chance to pick the brains of a couple of really expert fisherfolk. The lakes around here hold some lake trout, ling cod, bull trout, and Dolley Varden.  One person I talked to has never come back without a fish, and more than one told me about great spots to catch 28 pounders.  Of course we call fishing stories just that for a reason.  Still, after I bandage the wound, the cell phones come out and the photos of the fish have been very impressive.  The most common, and the most successful bait around here seems to be bacon.

Every morning and evening, when I enter and exit the hotel, I see the crews that stay here, too. Of course I expect the seasonal workers: the rail crews, pipeline workers, tree planters, and such.  But now I see firefighters rotating off the line, and I have attended a few in the clinic.

Today the raging forest fires brought in the first of what I anticipate will be a long series of people with respiratory problems. Those numbers might take a while to ramp up, but lungs show an acute phase inflammation, over the first few hours to days, and a longer term late phase inflammation that lasts 6 weeks.

The area doesn’t have many roads, and the fires have cut off evacuation routes south. Last week, at the town’s only thrift store (staffed by hospital auxiliary volunteers), Bethany ran into a family who had to flee the fires.



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.

A single digit error explains low patient flow

July 27, 2016

I said to the front office clerk

I hope I’m not being a jerk

Someone who works in hive

Wrote  seven, not five.

Now will you please just send me more work?

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

After two months of no patient care I returned to work three days ago. Patient flow crept in the single digits daily.

Still I had bloggable moments.

We dealt with a cardiac arrest the first day. Doing CPR constitutes a valid workout, and people fatigue so quickly that the guidelines call for a change of personnel every 2 minutes.  My turn came, and the hospital CEO followed me.

For different people with different problems that day I advised drastic alcohol reduction, complete tobacco elimination, good hydration, sleep prioritization, regular exercise, and a return to counseling. I pointed out that marijuana aggravates anxiety, deepens depression, brings on paranoia, and sabotages life goals.

Yesterday we watched through my office window as the crane lowered a new installation, really a prefabricated building with very expensive equipment, into place. The machine, worth dozens of millions of dollars, came down slowly, guided by men in hard hats with ropes.  I recalled my days in construction, when I swept the concrete footing furiously just before the crane lowered the form.  I looked at the odd clods of dirt on the footing and shook my head.  The stucco wall now sits three feet outside my office window, completely obstructing the view, and reflecting the heat from the sun.  I’ve quipped it’s a monochrome mural by a noted abstract artist titled Beige Wall, and offered to forge a Salvador Dali signature on it.

I performed my version of a complete neurologic exam on 4 different patients yesterday; all completely normal. I deal with a lot of patients with headaches, migraines and others.

But I also took care of a very sick patient. At the end of the day, I ordered a lot of lab work, all of which got sent to a reference lab an hour away.  I left my phone number with the techs, telling them that they could text me results without violating HIPAA as long as they didn’t attach a patient name.  And I could do so safely because I only had one patient hospitalized.

Today the low patient flow continued. The new installation required lots of drilling through my office wall.  I fled the intolerable noise to chat with a colleague.  But I also passed a front office staffer at a critical time.  She asked me my UPIN.

Various entities have assigned me various unique identifying numbers, starting with my 9 digit Social Security number. The longest one, with 14 digits, comes from Canada. I gave her the 10 digit number, flippantly, ending with 365.  She frowned.  The one she had on file ended with 367.

That one digit error resulted in no insurance credentialing for 5 companies. The clinic administration worked hard much of the afternoon to try to set things right.

While the drilling in the wall continued.

I thought about the Bob Dylan song, Lily, Rosemary and the Jack of Hearts.

Rabid arctic foxes and northernmost rotarians

June 10, 2010

I don’t want a lengthy deferral

When I ask for a timely referral

    There should be a prize

    For the abnormalest eyes

In a place that’s remoter than rural

Tonight a young man gave me his permission to write this much about his case.

I saw him last week some vague and improbable visual and neurologic symptoms.  Of course I examined him, and almost as an afterthought I checked his eyes.

His eye movements were alarming.

I’ve seen abnormal extra ocular movements before, always I’d known they’d be abnormal before I started the exam.

I presented the case at morning conference the next day; the thrust of my presentation was that he needed to be referred out, but I didn’t how to make that happen.  Later that day, per group suggestion, I called a neurologist at Alaska Native Medical Center in Anchorage, who agreed that referral needed to be made within a week.

Since then I’ve taken a personal interest in trying to get the appointment expedited.

The patient came back today, subjectively and objectively worse.  It took time and running around, but I made sure the patient got down to Anchorage in an accelerated time frame. 

I’ll be presenting the problems involved at morning conference, again tomorrow. 

After clinic this afternoon I was invited to the meeting of the Rotary Club, which lies north of all world’s Rotary Clubs, including those in Greenland.  Two of our docs are longstanding Rotarians. 

The meeting was at the Mexican restaurant, Pepe’s North of the Border, tonight serving Yankee pot roast.  I did however get to speak Spanish with one of the waiters.  About ten of us gathered for the installation of a new Rotarian, and a short speech. 

Just before the speech, my phone rang.  ER is swamped, and walk-in patients are stacking up. Could I please come?

No problem.  It’s a four block walk in gorgeous weather.

I can’t talk about the patients I saw.  I can talk about the current problem here with rabies, being carried by arctic foxes, and how it complicates the treatment of all bite wounds in a town where animals, wild and tame, live close to humans.

People seeking narcotics are a common problem in medical practice throughout the US, and Barrow is no exception.  In Sioux City I established a reputation early as never giving narcotics for migraines and very rarely using narcotics except when the diagnosis was well established.  My reputation has yet to be made in Barrow.

My Inupiak vocabulary grows; I learned to say “I’m fine,” which if said too fast becomes “I’m crosseyed.”  I also acquired the words for gallbladder, dirty, whale, and I don’t know.

Tomorrow will be 21 days since my career change, the three-week rule applies.  I will have to be extra careful.  I’ll shorten my work outs, watch my words, and take no chances.