Paper Order Joys and Outpatient Dictation

If it helps to make a decision

We like a CAT scan’s precision

It sure made my day

When in truth I could say

It looks like you’ve dodged an incision.

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. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. 2017 brought me adventures in Iowa, Alaska, and northern British Columbia. After a month of part-time in northern Iowa, a new granddaughter, a friend’s funeral, and a British Columbia reprise, and my 50^th High School reunion, I’m back in Northwest Iowa.  Any identifiable patient information has been included with permission.

I arrived 15 minutes early for a brand-new gig. I started the usual orientation: meeting a lot of people whose names I forget and shuffling around a confusing geographic set-up.

No one expects me to remember everything the first day, but much like any other human learning endeavor, one has to find a starting point,

The facility has three EMRs, one each for the hospital, the clinic and the ER. The ER and hospital systems communicate with and resemble each other, but do not qualify as twins.  And I’ve used the hospital system before, in Nome and in western Nebraska.

The outpatient system, however, looks like nothing I’ve ever seen.

For reasons I don’t completely understand, my schedule keeps changing, and I covered an outlying clinic in the afternoon.

I cared for 5 patients, including 2 children, both of whom I mesmerized with my yoyo. I managed to not increase anybody’s prescription burden, recommending only agents available over-the-counter.

Not a single patient came to the ER that night, yet the vigilance of call kept me up.

I only attended 8 outpatients and an inpatient the next day, yet high-stakes clinical material dominated the landscape. I sent two patients to the CT scanner down the hall.  Surprisingly, the results swayed the decision-making process in both cases.  Neither went to surgery nor to inpatient.

A different patient became my first admission to the hospital. The wonderful nurses gave me the choice of writing my orders or entering them into the computer system.  Grinning, I took the hand-written option, and later watched a new-hire nurse struggling through an unintuitive system.

The glitch that prevents me from using the outpatient system for entering lab and x-ray orders or for electronic prescribing continues to defy resolution. The management here lets me write my orders on plain paper and have the nurse enter them into the computer. I dictate my notes.

And I finished on time. For whatever reasons, for the time being I can enjoy slow patient flows.

The patients have already started asking if I’ll move here. Forever.  I thank them, but I decline; Bethany and I still have more adventures to look forward to.

 

 

Rounds from Dawn to the Newborn Nursery.

 

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 6^th 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. 

 

 

A hospital without surgery, down the road from a mobile OR

The hospital’s a hundred years old

And I watched the drama unfold

    No dark and no gloom

    In these inpatient rooms

Built during the rush for the gold.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical avoid burnout, while my one-year non-compete clause ticks away I’m having adventures and working in out-of-the-way places.  After four weeks in Wellsford, on the North Island of New Zealand, I just arrived at my new assignment.

I drove the plains east of the Southern Alps, low white clouds racing across clear blue skies, to my first morning at the Waikari clinic, where I found the mobile surgical unit parked.

People face a long wait for elective surgery in New Zealand.  To ease the burden on the hospital facilities, Christchurch has a mobile operating theater that travels the outlying areas. 

The US medical system includes a number of specialty hospitals for low risk surgical operations, but the larger hospitals complain about cherry-picking.  Here the bigger institutions send out a mobile Surgi-center.

New Zealand’s approach involves less bricks, mortar, and whining.

A tour of the interior showed a modern OR, including scrub sinks and anesthesia. 

The roster (=schedule) included patients with umbilical hernias and hemorrhoids, procedures which needed general anesthesia and an OR but not much recovery afterwards.

It seems like a good idea to me, something we could probably start up in the States, but unlikely to occur because the Joint Commission on the Accreditation of Hospitals would never approve.

The manager showed me around the clinic.  My office for the next four weeks looks much like the offices I used for the last seven weeks in Wellsford/Matakana, and I asked if the furniture came as a standard issue.

I don’t like the layout; a desk separates me from the patient. 

They asked me if I’d mind making ward rounds at the hospital.

Not at all, I said, but I hadn’t known one existed.

Walking distance up the road, the hundred-year-old Waikari Country Hospital commands a striking view. 

I don’t know when surgery stopped at WCH, but I met several people who had been born there and talked with others who had their babies there.  The midwife movement has taken over non-operative obstetrics in New Zealand, most babies deliver at home or in birthing centers. 

The hospital here has facilities for emergency childbirth, but no operating theater. 

Nor do they have lab or x-ray.  A courier collects blood work once a day, and patients needing radiologic studies get sent to Christchurch; thus the clinician relies more on physical exam and reasoning than on imaging or test results.

The hospital here cares for people who don’t need an acute hospital bed, but who cannot go home.  Some come for respite care, some for terminal care, and some for fine-tuning of chronic problems. 

The atmosphere stays quiet and restful, and the Victorian architecture lends a touch of grace, but the last earthquake cracked walls that had never been cracked before.

Charts remain thin despite long stays.  Reducing paperwork keeps nurses efficient and the staff small.

The Joint Commission would never approve.

Chickenpox, shingles, and widows. Drama=irony, surgery=theatre

For lunch I had me a pie

I went back to work bye and bye

          I am no cheater

          If surgery’s theatre

I won’t make the audience cry.

 

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, right now I’m working on the North Island of New Zealand.

I arrived early at the clinic in Snell’s Beach and started work in the quiet of the morning.  With the doors of the clinic open to the sunny, cool air, I reviewed lab and x-ray results; four of fourteen needed follow-up.

When patients started, I refilled a lot of prescriptions, many of them for asthma.  A lot of kiwis have asthma, mostly unrelated to smoking.  The commonest combination, salbumetol and flixitide, would be called albuterol and fluticasone in the States.

In New Zealand, surgery refers to seeing outpatients.  What we would call surgery at home gets the word theatre here.  Thus whereas in the States “Have you done much theatre?” might mean anything from “What live acting credits do you have?” to “Are you gay?” the Kiwis mean “Have you done many operations?”

At lunch I stepped outside into perfect weather, with cool, breezy air and bright clear sunshine, and went to the bakery for an unhurried steak and curry meat pie.

Back at the clinic I’d started tidying up my documentation when the nurse said, “I know you’re still on your lunch break, but…” 

In fact, I’m not used to an hour lunch break; at home I got into the habit of bolting my meals.  Of course when I got the opportunity to do what the locals would call theatre to help a patient cope with the consequences of steel’s excess kinetic energy contacting flesh I said yes.

When I finished I found myself twenty minutes behind schedule.

I’d almost caught up by 4:00 when a patient asked for a letter for court.  I couldn’t contact the requesting lawyer.  I made it clear that both parties had to be comfortable with the letter, and I would only write truth but not conjecture.  I wrote, we edited, and in the end, the piece of paper left with the patient but the process took twenty-five minutes.

By 5:15 I’d seen 24 patients and written refill prescriptions for another.  One third of my patients, both male and female, mentioned their status as widows.  Half had been widowed more than once, all wanted to tell their stories, and the drama and irony of the human condition flowed raw and unrestrained.  I listened with sympathy.  At one point I mentioned the high rate of spousal death.  “Oh, yes,” the patient said, “Snell’s Beach is full of us.”

Four of the day’s patients had superficial skin infections.  One had shingles, and I remarked that if it didn’t presage a chickenpox outbreak it would constitute a unique experience in my career.

I drove the rough, narrow, winding road with dense traffic and courteous drivers to the clinic in Wellsford.  I checked in with the nurses, and a flurry of confusion followed.  With my name on the roster (as they call the schedule), and another doctor’s name on the computer template, I had the option of taking off and going home.

The thought of another forty minutes on the roads pushed my decision to take the night on call, thereby earning me a dinner break and collegial gratitude.

I walked down the street, gobbled mediocre steam-table Chinese food, and walked back in the gathering gloom.

The anticipated chicken pox outbreak had arrived, the pharmacy (in Kiwi, the “chemist’s”) had closed, but I rooted through the after-hours drug dispensary and found, to my surprise, a good supply of aciclovir.

Any advertising appearing here does so without my permission or endorsement.

Thirty-eight CT scans later, life’s lessons from a musician and a teacher

We count good moments, not years

When we don’t give in to our fears

     I once went with a hunch,

     It helped my patient, a bunch.

And she looks good in front of her peers.

My patient, Diane, has given me permission to use this information in my blog. 

She taught my three children instrumental music; she came to me as a patient more than a decade ago.

Six years ago a cough brought her in.  As with all health professionals doing their job with a woman between ten and sixty, I asked if there were any chance she was pregnant. 

“No,” she said.

Sometimes I get a hunch and a long time ago I learned to trust that tingling at the back of my brain; in this case it told me not to believe her. 

“Well,” I said, “Just lay back on the exam table while I check your tummy.” 

I plainly felt the top of her uterus higher than her belly button, but I couldn’t find a heartbeat with the Doppler.

I pled urgency with an OB-Gyn and got her an appointment within the hour.   The ultrasound showed her womb had turned into a malignancy the size of a soccer ball.

A few weeks later, she came, in her words, to a “critical decision that I make a ‘leap of faith’ in action right before surgery, because I knew in order to live I had to not be afraid to die.”

The pathology report said leiomyosarcoma, a cancer of the uterine muscle.  In later years she said, “I was always a survivor from the beginning.  I was born C-section at 7 mo.[ 3.5 lbs] in 1960.  I had no idea how having ‘faith’, ‘letting go’ of past hurts, and learning to trust others would change my life all for the better.”

It helped that she had never been a bitter person.

I coordinated her care as she went from specialist to specialist.  So rare a tumor had no chemotherapeutic experience.  With a paucity of clinical evidence, I gave advice from my heart. 

“The worst day of my life wasn’t when you called and told me it was in my lungs,” she said.  “Not even close.  I’ve had more good days since my diagnosis than I had in my entire life combined.”

The next summer Bethany and I met Diane and her husband on their way out of the movie theater.  She’d been carded trying to get into an R rated movie.  Her skin had the clear glow of a teenager and her hair shone in the sun.  She walked with a bounce befitting a sophomore.   

The spring after that she sat in the waiting room of the Cancer Center before a radiation treatment.  The other cancer patients turned to her. “You’re not here for radiation,” they said, “you’re just another representative. What do you represent?”

“I represent hope,” she said.

My middle daughter fell rock climbing three years ago; in the aftermath of ICU’s and neurosurgeons and months of not knowing I learned a great deal.  Diane and I have discussed these truths: Time comes to us in moments, some good, some bad, most neutral; if you let the bad moments contaminate the neutral you give them too much power and if you let the bad soil the good you’re missing the point; embracing the uncertainty of not knowing bad news makes your day better.

When I made my decision to slow down back in February I also decided to bring music back into my life and buff up my saxophone skills by doing lessons with Diane.  On my last clinic day, she and her husband and my office nurse gave me a soprano sax.

(see my post https://walkaboutdoc.wordpress.com/2010/05/23/can-a-soprano-beat-a-naked-lady/)

Over the course of ten surgeries, seventy-nine radiation treatments, fifteen hospitalizations, and thirty-eight CTs, Diane continues to look younger and younger.  She serves as a beacon of light and hope to all who know her.