Posts Tagged ‘stroke’

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.


Morning rounds before Thanksgiving.

November 22, 2012

I started my work in the dark,

At the hospital next to the park.

Up and down floors

And in and out doors

The contrast and irony stark.

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 enjoy starting early.  On Mondays and Wednesdays I do my group’s hospital rounds, and I like being in that first wave of doctors that hits the nursing floor before the chaos of shift change.

The more efficient I get, the more I enjoy inpatient work.  A doc can save a lot of time if he or she starts at the top and works down but today I started with the sickest patient admitted overnight, on the fourth floor, not the sixth.

I gained time because comatose patients don’t talk, and lost every minute trying unsuccessfully to access the outpatient record electronically.   Faced with an unconscious, non-English speaking patient, no available family members or other source of data, I did the best I could.  I left orders for social workers with interpreters to locate family and clarify the Do Not Resuscitate status.

Down the hall, the next patient, also requiring a history and physical, presented a dilemma: a narcotics addict with a legitimate, acutely painful physical problem.  I wrote orders for generous doses of narcotics in a patient-controlled anesthesia (PCA) pump.

I dealt with nurses panicking about a rumored bedbug found in the ER, pointing out that wearing infection control gowns , gloves, and caps wouldn’t do anything to prevent the spread of real bedbugs.

On the other side of the nurses’ station, I discharged a large patient with a 14 item problem list, who will need outpatient IVs for weeks.

I didn’t see the last patient on that floor, absent for treatments across town, but the ward clerk told me when to return.

Five minutes here and there add up, chasing patients wastes time, and I could feel efficiency fleeing in front of me.

I set off upstairs.

Some people don’t stop unhealthy behaviors soon enough, and physicians like me sometimes have to sit down with families and talk about time expectations measured in a week or two.  We discuss ventilators, resuscitation, and the vital business of saying what you have to say to the people in your life NOW because you might not be around to say it on Monday.  The patient said, “I’ve had a good life.  I’m not afraid to die.”  I talked with the consulting subspecialist who confirmed a very poor life expectancy, and gave me a decades-old formula . My calculator came to 63 when anything over 32 means less than a dozen days.

Three doors down I discharged another patient, mixing Spanish and English, and getting pieces of a fascinating life story, an odyssey crossing and re-crossing international boundaries.

On the other side of the building, inside the locked doors of the psychiatric unit, I discharged a person showing remarkable insight and taking complete personal responsibility, after a discussion of the fine points of a borderline vitamin B12 levels.

Two stories down, I discharged another from the orthopedic floor, who also had vitamin B12 problems and severe vitamin D deficiency.  Two doors up the hallway, the patient showed progress but not enough to leave.

Up the stairs again on the fourth floor, five minutes fled while the patient arrived from across town.  Optimism suffused the visit with four family members and a patient with a grim diagnosis and a good attitude.

Two floors down another admission involved a newborn, with the shortest of histories and the most efficient of complete physicals.  I spent more time talking with the parents than actually examining the patient.

Thus in the course of my hospital morning, I took care of 8 patients including 3 admissions and 3 discharges (with discharge summaries).  Diagnoses included metastatic cancer, end-stage liver disease, hip fracture, kidney failure, dementia, end-stage pulmonary disease, bipolar, alcoholism, depression, diastolic heart failure, sepsis, epididymitis, diabetes, hypertension, coronary artery disease, stroke, narcotics addiction, sepsis, urinary tract infection, and completely normal.  Life expectancy ranged from less than a week to 86 years.  Family involvement went from none to surrounded by warmth, and emotional impact of disease ran the spectrum from despairing acceptance to outright joy.

Contrast is the essence of meaning.  I finished before noon.  I lunched with my colleagues in the doctors’ lounge, discussing hospitalized patients with consultants. The erudition beat the chili.

The difference between a medicine and a poison, the difference between the life of the party and a drunk

August 9, 2012

Tell me, what do you think,

About having the occasional drink?

If it’s one, sometimes two

It’s a great thing to do,

Any more and you’re needing a shrink.

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 took premedical classes as the University of Colorado at Denver.  My biology lab partner and I stayed friends.  In the fall of my first year of med school, she wrote me that she had multiple sclerosis (MS).  In 1975, very little could be done to change the course of the disease, which usually progressed relentlessly shutting down various parts of the nervous system.  Three years later, she mentioned going to AA, and I expressed my surprise.  When pressed, she said, “Well, you’ve got your high bottom drunks and your low bottom drunks.  And thank my Higher Power I’m a high bottom drunk.”

By that she meant she had hit bottom before a lot of things had gone bad in her life.  Later clinical experience showed me that MS and alcoholism frequently, though not always, go hand in hand.

The alcoholic who hits bottom early in the course of the disease does a lot better than the ones who hit bottom late. 

Not surprisingly, alcoholics get sick more often than non alcoholics; and smokers tend to drink and drinkers tend to smoke.  Thus I see the spectrum of alcoholism from those who learn early to those who learn too late, from those who function well despite their drinking to those who don’t, from those who drink daily to those who drink once or twice a year but go all out when they do.

I’ve watched alcoholics destroyed their families, finances, bodies, and careers without figuring things out.  On the other hand I have known alcoholic professionals who did something crazy on a dance floor, heard about it the next day, and never had another drop.  They never went to meetings, but a lot of them embraced their religion.

In between I can tell you stories of hundreds who quit just before their liver or their heart or their brain gave out for good, those folks who came back from the edge of the pit and lived to tell the tale though they lived the rest of their lives with significant disabilities.

Most people know about alcohol’s tendency to damage the liver, and we all know about liquor’s brain toxicity.   Yet most alcoholics who keep drinking and don’t die of trauma tend to die from heart attacks and strokes brought on by intemperance; booze raises blood pressure, brings hardening to the arteries, and directly weakens heart muscle.

But wait, you say, isn’t a glass of wine a day good for you?

Sure, just like labetalol 100 mg twice a day is good for some people, but if you save 3 months worth for the day of the Superbowl, it’ll kill you.  Thus a medication differs from a poison by nothing other than the dose.

And women who drink a glass of wine a day double their risk of breast cancer.

In my experience, a typical alcoholic is witty, fun to be around, unique, and intellectually stimulating when sober. And when drunk he or she is just another drunk.

A refresher in resuscitation and a visit to Te Papa, the New Zealand National Museum

March 16, 2011

I’m trying hard to decide

When everything else has been tried,

     What drugs should we give

    To make the dead live,

After a patient has died.

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.  Just back from a six-week assignment in Barrow, Alaska, the northernmost point in the United States, we’re in Wellington, New Zealand.  I’m prepping to work here.

The third morning of orientation today started with a discussion of emergency medical services in New Zealand, while concern about fallout from the Japanese nuclear disaster remained an undercurrent in everyone’s mind.

Four entities provide EMS in this country; three cities have their own, and St. John provides the rest.  They also do a lot of other civic stuff, including operating the largest youth group in the country.  There are four levels of providers. 

It came as no surprise that the lowest level of emergency service provider administers acetaminophen (Tylenol or Panadol) routinely.  It came as a shock to learn that the more advanced can also administer low doses of Fluothane, an inhaled general anesthetic that fell out of American OR favor in the ‘90’s. 

The higher levels paramedics are allowed to give small quantities of ketamine, which is closely related to angel dust or PCP.  It’s also a great general anesthetic, dissociating the patient from the pain experience, but sometimes people freak out.  I learned that in the low doses used by the EMS providers, pain relief is prompt and bad reactions are rare.

In some circumstances, specially trained rural GP’s attend trauma patients at the accident scene.  

At the Advance Trauma Life Support (ATLS) course I took in December, the instructors recalled the days when they went out in the helicopter and took care of trauma victims in the field.  Their faces lit up when they told their stories.  Doctors in the States don’t do those things anymore.

The instructor gave us a brief refresher in ACLS.  The Automatic External Defibrillator movement has just started here.

New Zealand has prioritized resuscitation to those people with a reasonable prognosis (for example, not those with massive stroke).  By comparison, the barbaric American way gives everyone gets a “full code” (including shocking, intubation, ventilators, and chest compression) unless a document to the contrary comes to hand immediately.

 Resuscitation trends have come and gone, algorithms have changed, and the rate of successful resuscitation has improved in the thirty-two years since I first took ACLS.  Most of the drugs originally recommended have been dropped from the armamentarium.  Since I took the Basic Life Support course last spring, chest compression only has supplanted mouth-to-mouth combined with chest compression.

But some things don’t change.  Our instructor mentioned his wife, now thirty-eight weeks pregnant and four hours away, and his concern.  I remembered back to February 1984, when we lived in New Mexico and Bethany’s second pregnancy went past her due date.  I worked at an outlying clinic forty-five minutes distant, and I hated leaving her.  I had no peace of mind till I started back home.

Three of the docs and two of the wives lunched together and went to Te Papa, the New Zealand national museum.  I was impressed by the wisdom and knowledge of our Maori tour guide, who has instructed at the University level in, among other places, Wisconsin. 

I would have loved to just sit and talk with him for an afternoon.