Posts Tagged ‘pediatrics’

Locks on the Clothes, Keys on the Shoelace: the dress of a millwright.

July 9, 2017

The millwrights has many a key

For the mill cuts up many a tree

On the machine go the locks

Preventing visits to docs

And keeping the workplace accident-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, 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.

Thursday I took care of 17 patients. One pediatric patient required all my patience, skill, and accumulated experience to get the job done without alienating the kid.  The oldest patients barely qualified as septuagenarians.

I wrote a lot of prescriptions for blood pressure drugs.

I used my deep-breathing techniques on three patients to bring blood pressures into the acceptable range.

Though only 15% of Canadians smoke, the nicotine addicted comprised more than half my patients.

I wrote several back-to-work slips, all employees in the timber industry.

I cared for even more millwrights and former millwrights. Changing logs into useable products involves a lot of dangerous machinery, and the people who fix the machinery come in loaded with padlocks on their clothing.  They lock a machine before they work on it, to make sure it won’t start accidentally.  Spare keys get carried where they can’t get lost, such as tied into shoe laces.  During the work day, a “whistle” signals a need for a millwright.

One of my patients in frustration said, “Can you give us a referral to see a specialist we can actually see?’ and we laughed after I asked for and received permission to use the quote in my blog. While I know my way around the human body, and most of the things that go wrong with it, I don’t know the local medical community.  Yet the permanent doctors trained near here, and know the consultants personally.

There’s also a province-wide network providing phone-in advice for docs . The consultants get paid on a fee-for-service basis; the patient has a unique identifying number, and the doc has a bunch of unique numbers (I have 8), one of which is the right one to use.  Computer algorithms coordinate compensation.

Iowa house calls, back to Pennsylvania

August 7, 2015

For a house call I went to a store
Then expected one or two more
To come to my house
So I said to my spouse,
They’ll come in through the front door.

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. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, and a bicycle tour of northern Michigan, cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

While home in Iowa last week I made a couple of house calls.

One patient owns a business I frequent, and had called me when we were both on the way back to Iowa. Our professional relationship dates back well into the last century. We have watched each other progress professionally and socially. He gave me the go ahead to write the entire visit in this venue as a record, but, for the same reason I conducted the interview on the deserted freight dock and the exam in the store’s quietest corner, I didn’t. At the end, he personally helped me with my selections and would not accept money for the transaction; nor would I accept payment from him.

Another friend has had a problem building for months; we agreed on the next step: the specialist.

The garden has come in, and Bethany and I snacked on the first of the tomatoes, cucumbers, and green chiles; We invited company for supper on Friday. For a side dish, I cut sweet corn from the cob, added red onion, roasted green chiles, lime juice, and olive oil.

I took call for my Community Health Center the weekend. One patient discharged from peds on Saturday and one admitted on Sunday,far cry from a census demanding two docs to round both mornings, with one up all night to take admits and calls.

Tuesday found us back in Pennsylvania, at an Urgent Care, working 12 hour days, but this time we can walk from the hotel to the clinic. I like the medical record system. I can whiz through documentation for respiratory problems, but skin and musculo-skeletal problems need more narrative because no two are the same. A disproportionate number of patients come in with poison ivy.

Urgent Care, by definition, doesn’t include ailments that need follow-up or CT scans. I sent a number of patients each with suspected heart attacks, blood clots, or kidney stones to the local ER. People with bipolar disease tend to have very real, severe physical problems. I can treat those injuries, but getting at the root cause falls outside my scope of practice.

To those patients who come in, for example, with weight loss (now into the double digits working for this client) I say, “This is not normal, but there is a limit to what can be known an hour, and there is a limit to the lab we can run in Urgent Care. You need a primary care provider, and here is a list of labs that he or she might run.”

Nor can I effectively treat rheumatologic problems, but rheumatologic patients come to see me nonetheless. From time to time I run into people on Enbrel, and then we generally have a happy support group meeting. We talk about how the drug changed our lives; how, coming out of the pain we could engage emotionally with our families; and about how, outside the pain relief, we just feel better; (I feel better now than I did at age 18).

If I talk to a back pain patient on opiates, I tell them how the medication inhibits their own ability to make endorphins and perceive endorphins. Some express shock and amazement, and some just want me to prescribe the Norco, because “it’s the only thing that works.”

Mission creep: a census grows and genomics comes now comes retail

April 10, 2013

Does a thousand seem likes it’s cheap?

Beware the assumptions you keep.

Don’t think that it’s strange,

There will always be change,

And ever the mission will creep. 

Synopsis:  I’m a family doctor in Sioux City, Iowa.  In 2010, I left my position of 22 years to dance back from the brink of burnout.  While my one-year non-compete clause ticked off, I travelled and worked from Alaska to New Zealand, and now I’m back working part-time (54 hours a week) at a Community Health Center.

Last night I took the handoff for a hospital census of 4, a record low since I started with this clinic.  Even though I arrived for rounds before 7:00AM, that number had grown by 3.  I whizzed through two admissions, three patients with kidney failure, one each with alcohol withdrawal and complex pneumonia, five diabetics, a newborn, and two coronary patients.  (Do the math, you’ll figure out that a patient rarely enters the hospital with one problem.)

The longer a person lives, the richer their life story; and in the course of half an hour I had the treat of listening to a wonderful family history unfolding over the course of three generations.  I left them hope that the specialist would be able to cure the problem. 

But I squandered 15 minutes trying to educate a nurse, who overhearing me speak Spanish, made disparaging remarks about immigrants. 

Still I finished at the one hospital before ten.  At the second hospital, still in the throes of transition from paper charts to a new Electronic Medical Record (EMR) system, I only had to round on the pediatric floor, and I held onto hope of getting to the office early. 

I discovered an EMR quirk: one now needs 9 keystrokes, not 1, to edit a dictation.

I got to the office early, but not nearly as early as I’d hoped.

After half an hour of buffing documentation and messages, I attended what had been billed as a provider meeting.

The man who brought the lunch didn’t pitch a drug but a lab test.  Using material on a cotton swab from the inside of the mouth, for a mere thousand dollars, his company can provide us with genomic information about how fast or slow a person might metabolize a range of medications. 

For example, a single standard 30mg dose of codeine provides good pain relief for 80% of the population.   But 20% of population lacks the enzyme to convert codeine to morphine; for those people, codeine might suppress a cough but won’t relieve pain.  The super enzyme found in 1 in 3 Somalis converts 100% of the codeine to morphine on the first pass through the liver, enough to kill half of those who try it.    

Our clinic prescribes almost no codeine.  For whom will the test bring a thousand dollars with of benefit when it comes to choosing an antidepressant, antipsychotic, or ADHD medication?  We requested more information.

I didn’t ask the larger question: how long will it be till an entire genomic sequencing becomes available for that price? 

Mission creep remains a permanent fixture on the constantly shifting medical landscape.  Whether a doctor deals with a growing census, or a company sells technologic improvements, we all know that the world, at the end of the day, will not be the world we had at the beginning.

 

 

Rounds from Dawn to the Newborn Nursery.

July 26, 2012

 

Sunrise in the ICU

I started the day making rounds

Checking the lungs and heart sounds 

 

It started with dawn,

Where has the day gone?

Beauty is where beauty is found.

 

 

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.

I started so early that when I saw my first hospital patient, a perfect sunrise broke as I entered the room on the top floor of the hospital.  The water content of the atmosphere blocks the view of the sun most days till the red disc has ascended well above the horizon, but with the hot dry weather we’ve had, there was the sun, just peeking up.  And the ICU offered a spectacular view of the city in the morning.

The patient couldn’t speak and could barely respond.  Even if the patient can’t talk, I speak to him or her, tell them who I am, the date, where they are and why they’re there, and I try to give a few headlines from the news.  In this case I called attention to the phenomenal sunrise, but the patient didn’t look. 

From the ICU on 6th floor I went to see a new admission on 5 Medical, and discharged a patient who had recovered enough to go home.  Striding down the corridor to the opposite end of the hospital I came to 5 Behavior Health, the psychiatric service.  I did medical consultations on two patients admitted during the previous 24 hours.

The psychiatric portion of the service consists mostly of people who didn’t ask for their problem but got it anyway.  A surprising number of schizophrenics also qualify as bipolar.  More than 90% smoke, and a lot of them come down with type I diabetes as their pancreas withers away.  They lose years of life.  A majority of schizophrenics also have drug and alcohol problems, and they can’t learn from their mistakes.

Our society has failed our schizophrenics.  At one time institutionalized, they were turned onto the streets when the institutions closed, and went right into the criminal justice system.  The ones who stay out of incarceration use a lot of health care.

Fourth floor holds the oncology (cancer) and surgery nursing units on the south.  Contrast being the essence of meaning, I talked to those who know they have no cure and to those with a reasonable expectation of cure.

The pediatrics wing sits on the north end of the fourth floor, and I had no patients there.  Fewer and fewer children need admission to the hospital as the years wear on.  Vaccinations have prevented most measles, mumps, chickenpox, polio, rotavirus, pneumococcal, and meningococcal disease.  We see a tenth of the croup that we used to.

On the third floor orthopedics unit I did two consultations for people after total joint replacement, and on the second floor I took care of two newborns.

Death, the ultimate drama and the ultimate irony, came to three of my patients during the day.  One in middle age died surrounded by grieving family.  One went unexpectedly and alone.  A third died so old and full of years that few remained to note the death, though many, on reading the obituary, will sigh and reflect on how the passing impoverished the world. 

 

 

Atraumatic pediatric exam and a show at Pepe’s North of the Border

June 20, 2010

I play with the kids, I don’t fight

I show them the otoscope light

     The child will freeze

     I don’t have to say please,

I just have to leave out the fright.

I have the patient’s mother’s permission to tell the following story.  When I walked into the room the toddler looked at me and started to scream.  I Purelled my hands, greeted the mother, set down the paper chart and took out my yoyo, while the child wailed.  The volume diminished by less than a decibel while I ran through Sleeper, Walk The Dog, Rock The Baby, and Split the Atom.  While I was playing with the yoyo I interviewed the mother about the child’s draining ear:  when did it start, what color, is there fever, has the appetite gone down, what about cough, any allergies, any smokers in the home.

After that I sat down and played peek-a-boo with the patient.   To play really good peek-a-boo, hold a visual barrier (such as the chart) between you and the child, move the barrier and say “peek-a-boo.”  Over the next seven or eight rounds of peek-a-boo, the volume of the crying diminished, ceased, and was replaced by a smile.

I fished the otoscope from my pocket.  I showed the child that the instrument was not to be feared by touching the mother’s hand and showing him where to look.  Then I touched the patient’s hand and said, “Hand”.

Children in the language acquisition phase will freeze if you touch them and name the body part.  I usually get enough time to examine the ear without restraining the patient, but I rarely get more than eight seconds.  Rewarding the kid with applause, he turned his head without being asked.  

We played our way through the examination; he resumed crying when it was over.

All in all, covering the outpatient area yesterday didn’t strain me. Patients came in twos and threes; the clinical mix was interesting but not overwhelming. 

When I note tremor, high blood pressure, weight loss, heat intolerance, thoughts racing, insomnia, and pulse over 90, I think about hyperthyroidism.  If the patient looks too much like the textbook description, though, I’m usually wrong.

One of our colleagues, another locum tenens doc, agreed to cover for me starting at 4:30 so our band could play at Pepe’s North of the Border, Barrow’s Mexican restaurant.

We have a guitarist, a trumpet player (another doc), and me on saxophone.  All three of us sing.  The guitarist and I agree that the trumpeter should be the leader; he does a good job of organizing and encouraging us.  He gets us the gigs, he organizes the practices, and he picks the tunes.

We play Celtic, old standards, fifty’s rock ‘n’ roll, and country. 

We opened promptly at 5:30 with St. James Infirmary.  We don’t try to overwhelm the crowd or get them to pay attention; we like to see heads bobbing while people eat. 

At 7:00 a group of ten sat down directly in front of us while I was soloing on Summertime, which brought out my latent attention deficit, and I had to ignore the sheet music and improvise.

I condensed six months worth of emotions, seasoned it with the triumph, tragedy, drama and irony of the patients I’d seen that day, and I played about my freedom.

The number drew applause from a tough crowd.

In the last half hour the room was packed; our harmonies worked, our improvisations soared.  We played beyond the allotted time and nobody objected. 

The gig was over when the band leader had to bolt to work the emergency room.  He’ll be gone this coming week, covering the isolated village of Wainwright. 

Our next gig is the hospital barbecue, next Saturday.