Posts Tagged ‘pneumonia’

Weekend call: nature abhors a vacuum

March 27, 2017

I took the weekend on call

I started with no patients at all

But I fixed that up quick

With the ill and the sick

The thin and the fat, the short and the tall.

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.

 Perfect people don’t come to see me. When I find a patient who has to face the music and pay the piper, I do my best not to judge.  Strangely, when I can condense my approach to, “You’ve made mistakes in the past, let’s move forward,” I find it easy to establish rapport.  I like to think that the rapport brings better chance of patient cooperation in lifestyle modification.  At the very least I have more energy at the end of the day.

In residency and in private practice, when I would take sign-out for weekend call, I would look first at the gross number. Of course we like it when no-one occupies a hospital bed.  But if the number came in really low, I’d shudder and remember the adage, “Nature abhors a vacuum.”

This weekend, I started call on Friday afternoon with a census of 0. By the time Saturday morning dawned, the census had climbed to 5.  Most, not all, had pneumonia.  Most, not all, sickened from a combination of tobacco damage and the aftermath of the influenza. I went into a rhythm of admission history and physical.

I dictate with sophisticated software. Still, sometimes I get so frustrated that I use my well-honed keyboarding skills.  For example, dictating a list gets me correct numbers except “4” which prints out as “for.”

And beneath the commonalities of fever, cough, and wheeze, each patient has a unique circumstance, a story of drama and irony that brought them to illness. And almost all have come at a time of stress in their lives.

Nothing is 100% in my business. A very few patients sickened gratuitously.  A genetic accident should not constitute a death sentence.

I enjoy talking with the patients. I ask them what they do in their spare time if they haven’t told me before I get to the question.  Over the years I’ve acquired enough vocabulary to speak meaningfully about a wide range of subjects.  Particularly in rural America, being able to talk about farming, crop yields, soil management, firearms, archery, and hunting gives me credibility.

Here in Clarinda, close to St. Joseph, Missouri, I ask people my age and older if they remember the Jerome Hotel.

It belonged to my grandfather. I drop his name.

 

 

 

Advertisements

Spanish at the dairy

November 17, 2016

The cows they are many, the workers are few

Spanish is spoken by all of the crew

I just love a caper

With records on paper

The time in the morning just flew.

 

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. 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. 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, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

Yesterday morning my first email asked me if I would mind going to do dairy workplace physicals. I would get two nurses, records would be on paper, and business would be conducted in Spanish. I asked how much I’d have to pay; the clinic manager laughed.

I saw a win-win-win situation.

This morning I checked Googlemaps and put the address into my GPS. I didn’t think anything amiss until she had me turn right at the edge of town.  Which didn’t quite look like what the map had shown.  I followed the electronically feminine voice until she told me I’d arrived at my destination.

I looked around at a plum thicket, some pasture land, and a grain bin. Definitely not a workplace.

The first person I passed, a trapper throwing a muskrat into his truck, shook his head, and gave me some convoluted directions. As I made the first indicated turn, I hailed another driver approaching.  He got out of his pick up when I asked directions.  He shook his head, too, and then he laughed, and asked me if I’d used a GPS.  I had to admit I had.  Such electronics, he said, don’t work on country roads, and he’d seen plenty of others, including semi drivers delivering goods, make the same mistake.  From his economy of delivery, I could tell the directions he gave had been given dozens of times before.

Three miles later, I got onto pavement, then back onto a dirt road, and arrived at the dairy.

The two nurses preceded me. Halfway through set up, we discovered we didn’t have disposable paper to cover the conference table to turn it into an exam table and we had to phone for a roll.  But I ran through the questions with the first patient, and started the exam.

The learning curve lasted 3 patients, then we fell into a rhythm.

Eighty percent of the physical abnormalities occurred in the head and neck, several serious enough to require follow-up. Not surprisingly, like most American patient populations, I dispensed a lot of advice on binge drinking, tobacco cessation, and dietary restraint.  But every dairy worker gets an enormous amount of exercise, and I didn’t tell anyone to get more.

About half the people came from Guatemala, half from Mexico. We had a good time talking about Mexican cooking.

I learned that the dairy milks more than 3,000 cows twice daily and that the milk gets hauled less than two hours.

When I asked what work they’d done before coming to Iowa, I got surprises. At least two (who gave me permission to write this) finished veterinary school in Mexico.  I didn’t understand what they told me about licensing (after all, I’m 20 months into trying to get a Canada license and I couldn’t explain what I’d learned in less than an hour), but I found out that the three most common diseases they see are pneumonia, mastitis, and laminitis, a problem with the hooves.  Others had university degrees in other areas of expertise, and all wanted to learn English.

I recommended Rosetta Stone.

We finished 15 complete physicals by noon. I lunched at the restaurant the workers recommended.

I make better enchiladas.

 

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.