Little Moments in a Big World

Interesting Moments in Pediatric Medicine:

Realizing that pediatric nurses, despite their teddy bear scrubs, will cuss, smoke cigarettes, and make fun of whiny kids behind their backs.

Picking up a previously undiagnosed heart murmur during a visit for vision change. And being reminded why I listen to the heart and lungs in every patient every time.

Realizing that kids actually are hoping that the X-ray will show a fracture, as it is a much cooler diagnosis than "contusion".

Being asked by a teenager to explain to him what a MILF is. And going for it, with the blessing of the parent and preceptor.

Telling a mom that her son's "Gait Disturbance" is because he is wearing shoes that are twice the size of his foot, and loosely tied. Rx: Nike Outlet down the road.

My wife "stealing" the prized quilt from the Clinic Owner in the Christmas Party Gift Exchange. And watching my evaluation go down the tubes.

Realizing that the child who cut the tail off the family dog and stabbed a teacher with scissors then repeatedly punched self in face until bleeding, and is now in handcuffs, foam helmet, 4 point harness seat and spit mask needs to have my fingers near his mouth, just as the guards tell me he likes to bite.

Referring for evaluation for medical marijuana for chronic pain.

Pneumothorax in a 6 hour old boy.

Still not understanding the whole immunization schedule. Thank God for the aforementioned pediatric nurses. Despite their sailor-like attitudes, they can certainly help me decipher the IPV,Hep,VZV,PCV,MMR,HIB,DTAP,TDAP madness.

Having the moment of clarity, which led me to utter the words, "I could do pediatrics...."

Can't Beat the Odds

I officially can now be lumped into the "every student that comes to this clinic gets sick" crowd. I thought I was going to go unscathed. I heard the statistics. I knew nobody had ever made it 6 weeks with a clean bill of health. I had my daily vits, my 2 daily clemintines, my cat-like reflexes for dodging respiratory droplets, and various other "jump the chalk line" superstitious, knock-on-wood type methods of evading the virus. I even washed my hands a few times. In other words, 079.99

On a side note, I thought I experienced my first earthquake last night. I woke up to the bed

shaking, the walls vibrating and an overall bumpy feeling in the room. My first thought: Chris (geologist brother) is going to be so impressed. My second thought: Is Chehalis even near a fault? My third and final thought: Why did my landlord just start their dishwasher at this hour?

They apparently own the 1973 model that has such an intense cycle, it is a threat to the structural integrity this house and my patience. I think a quake would have been milder.

High Points

A decidedly non-medical post. After 2 weeks of seeing 20+ sniffly kids a day, I am little burn out. Would rather post some photos of decidedly non-medical trips we've taken over the last year in a half. So here is a Northwest Volcano Pictorial:

Mt. Adams from a fire lookout

Mt. Baker from a ferry

Mt. Hood from a ski tour

Mt. St. Helens from Mt. Adams

Mt. Adams after our car almost almost caught on fire.

That's all. Will now resume regular programming as scheduled.

Rising Waters

9am-5pm Day Clinic; Saw twenty kiddos in varying states of stress, illness and general outrage toward me and my otoscope.

6pm-9pm Night Clinic; Saw seventeen kiddos with varying degrees of vomiting, diarrhea, and general fluids erupting from orifice.

10 pm Home in Cold Attic; I learn that the waters are rising on the Chehalis River and the Newaukum River. River will reach flood stage tonight or early tomorrow a.m. Interstate 5 may close which would prevent me from getting to the clinic. Apparently if the Skookumchuck River gets to Phase 2 (not that high) then I will not be able to leave the house, as the small Dead End street I live on will be surrounded. At least I live in the attic.

Photo from Today's Lewis County Newspaper

Breathtaking

Nurse Practitioner (NP) student comes barging in out of breath, late on her first day. To be fair, the fact that she is an NP student doesn't mean anything. She could be a PA, MD, DO, PT, MA, or MSW student. She could be a law student or a MBA student. I don't care. But, truth be told, she is an NP student. And she is a train wreck.

Within 10 minutes she is already starting an argument with the PA about how much better NPs can and will be because they can practice independently.

Within 20 minutes the clinic staff have all heard how amazing she is and how much vast experience she has as a nurse, including how many IVs she has started in her life.

Within 35 minutes, I begin to wonder why she is still out of breath.

Within 36 minutes, I realize that perhaps she is out of breath because she is about 6'1, 260 lbs, built like a linebacker that doesn't do any linebacking anymore. I think she has COPD.

Within 2 hours, I have learned that she owns 5 boats, owes next to nothing on her house, and is for the most part the master of all things disease. At this point, I begin to think she is just out of breath because she never stops spewing words out of her trachea. Her poor vocal cords are too busy vibrating to let in some good old Room Air.

Within 11 days or so she will be gone, as her program only requires 90 hours per rotation. I will stay for another 20 days and 150 hours. But then again, I am not the master of disease. And I don't even own 5 boats.

Attics and Locusts

I find myself alone in a cold attic bedroom, in a strange town halfway between Portland and Seattle. Life as a traveling PA student, at the mercy of the next clinic, the next preceptor, the next dress code, the next temporary landlord, the next temporary landlord's water heater.

Can't complain too loudly, as I've got hi-speed wifi, a roof keeping out the incessant Washington rain, and plans to drive back to Portland tomorrow. Saw my first kid today who was born with meth in his system. Now there is somebody who could reserve the right to complain. His insides don't work so hot.

Shared the clinic with a NP student today. Wow. That is all I am saying for now. If I give it a few days, I will have material for miles.

On a historical note, this is my second rotation in a rural county seat. The first one was known for a Great Fire. This one apparently had a Great Flood. I feel like I am on a tour of modern day Plagues. If my next rotation has locusts or frogs falling out of the sky, I'm done.

Sin Numeros

"You guys and your numbers...", Audrey says after skimming my blog, something she claims to do anytime there is medical jargon or numbers involved. It is true that my audience is likely a mixed bag: A few fellow students that may think it's neat that I saw a twelve year old with pulsating pupils with adrenal insufficiency and some family or friends that just like updates assuring them that I am not locked up in a Tijuana Jail.

So, for the mixed bag I try to bring a mix. I may write "UTI" one day and "bladder infection" the next. I am a little biased to "UTI" because: a) it sounds like I know what I am talking about b)it is shorter to type c) it's less gross then "bladder infection". Funny how the laymen term is more descriptive, a little more "in your face."

Heart Attack = MI
Anal Warts = Condyloma acuminata
Patient wants to Kill Herself = Suicidal Ideation or SI.

I'd rather have Condyloma twice then anal warts ever. I could go to the Walmart Clinic for an MI, while I may need an ambulance for a heart attack! People see SI and think you have a nice magazine subscription, not a need for anti-depressant prescription.

So I walk the balance of not freaking you out, not boring you to death, and not sounding like a total dork. So you will notice not one single number in this post. I even typed out the word "twelve". Enjoy, because tomorrow we may be back to statistics, percentages and other not-so-titillating minutiae of medicine.

Oh and I watched a circumcision today. Which is medical jargon for strapping a baby to a board, stabbing needles in and around the groin, slicing, dicing and removing his foreskin, and leaving behind a bloody penis, then handing the baby back to the Aunt, because the mother is too freaked to watch any of it, and you don't blame her.....see it's just easier to type "circumcision".

Day 1 Again

First day, continuing with some more numbers....

7 viral URIs, ages 2,3,4,6,6, 7,11

2 ear infections

1 strep throat. I love the Centor Score.

19 yo F dysmenorrhea. Preceptor was surprised she would talk to me.

18 yo F tooth pain. Get a dentist.

11 month old new patient for the HinnyVax

17 yo F "Influenza A" , orthostatic, dehydrated, IV start, first one in a while. She was too lethargic to care. Just like my first IV ever, oh wait he cared but he was just wearing handcuffs.

Unlike internal medicine these people are young and "under-medicated". The drug rep sharks could be circling outside the clinic. Fast, fun day. Oh and the somewhat creepy picture below are not my patients, but a visual clue for anybody that didn't realize I am now in my pediatrics rotation. I promise no more blooming christmas tree shaped pediatric poster children.

Numbers

Rotation 4 by Numbers:

Miles Driven: 3,358

Patients seen: 182

Tamiflu Prescriptions Written: 1

Patient’s with Dengue Fever: 1

Vaccinations Given: 0

Vaccinations Received: 2

Visitors: 3

Combined years knowing the 3 visitors: 75

Surf Sessions: 41

Fish Tacos Eaten: 8

Leopard Sharks Swam With: 54

Incidents involving lacerations: 2

Sutures Received: 7

Rotations Sites Left: 4

Pediatrics is next…on to the 7 year olds, after a rotation full of 70 year olds! Ears, rears, and mother's fears here we come!

TJ

After a great visit from brother Chris, there was only one thing left to do. Vamos a Mexico! Turns out, I should have taken Cialis orders for a few patients.



Against the advice of my preceptor, I walked into Mexico, alone. Last time they gave me a Wednesday afternoon off, I returned with stitches, so I understand the hesitation. But a two hour stroll across the border simply provided lots of family friendly entertainment. I was offered Vicodin at least 8 times, among other various legal and not so legal substances. One hombre called to me "hey guy my friend I have what you are not looking for." Exactly.

Felt the endorphins kick in with the sound of Spanish, the ripe smell of diesel exhaust mixed with garbage, the sight of rifle-wielding cops, the awareness that I was the foreigner. Smiled at the hucksters and the cabbies and the pharmacists. Love the way people drive and honk, love the music blaring from each empty cantina and love the mariachi band members getting their shoes shined on an otherwise boring Wednesday afternoon. Spent exactly one american dollar while here, on a Tecate. It was cold, refreshing, and funny how they always taste better south of the border.

Got back to los estados unidos in time for an evening surf session.

Now I am officially ready to head North. Get me out of here.

A Break but not Broken

A longer than normal hiatus due to:

• A long period of "work-surf-work-surf-work-surf..." gets a little old rubbing it in to all of you land-locked who don't get to taste the salt of the sea on a daily basis. Also not much to report at the clinic other than..."I actually kinda like it..."
  
• A lack of internet preventing me from sharing up to the minute updates on my laceration sustained while surfing large Hurricane Rick affected swell. 7 sutures in my forehead and a whole boatload of crap from the clinic personnel later, I am in a state of recovery with a long modeling career ahead of me.
• Audrey visiting...so all communication goes on shut-down. We snorkeled in the clear blue water, kayaked with sea lions, ate amazing mexican food, drank NM's potent margaritas, and *watched* the non-wounded surfers do their thing at all the right beaches.

I hope this finds you all well, in good spirits, free of head wounds, with belly full of your favorite fruit or vegetable. See you Portlanders soon.

LA,CA

Went North this past weekend to catch the final regular season Dodgers game. If they hadn't won the night before it would have been a very important game, to decide who won the NL West. But they were post-clinch, so the game was less important than the atmosphere, which was one of laid back celebration. L.A. has (at least) 3 former Cleveland Indians with Manny Ramirez, Casey Blake, and Jim Thome, so I felt OK about rooting for them. Plus I've never been a fan of any Denver teams, so to watch the Rockies lose was satisfying. Thanks Sean's Mom and Dad for the great tickets!

Back to the clinic for week 2. It has been a good mix of chronic care, acute complaints, thick charts and simple bee stings. I thought I could fend them off, but after 3 drug rep free rotations, the henchmen for the likes of Pfizer, et al have found me. They come bearing breakfast, lunch, and afternoon coffee and snacks, so as a poor hungry student I fell quickly to their methods. I am currently working on my strategy to increase the free food : jabber ratio.

Week One in Cali

Here are a handful of pics I grabbed this week:

The drive to Southern California was both beautiful....

...and typical.

My local surf break has it all: close parking, rip current for easy access to the outside, a pier for people watching when waiting for the next set (and for watching the true rippers "shoot the pier" which essentially means hurling yourself down a wave on a surfboard toward and through the concrete girders of the pier.), friendly locals that accompany me in the water late into the evening, and a lively apres surf scene with bustling restaurants, bars and a farmer's market on the street 2o yards from the beach.

The morning view from the kitchen as I eat my banana have been nothing less than spectacular. You gotta click on this pic for better detail:

I am not the only one who commutes with a surfboard:

No photos available from the clinic, but imagine if you will, me in a white coat with salt water in my ears, running around a small clinic in a big hospital attempting to eliminate disease, one lipid panel at a time.

Sandy Eggo

I actually thought of calling San Diego, "Sandy Eggo" while out surfing this evening after work. I googled it to see if I was original. They already have sweatshirts made. Google had 58,00 hits for it. In fact, I think it may have actually been the original name for this city, before they changed it to San Diego. Further proves my point that hardly any thoughts are original these days. People do everything, all the time. It's just go, go, go in this world. Hard to keep up.

Anyway, I'm here. Haven't seen any waffles on the beach yet. But it would be a nice place to have breakfast.

Plan by Pictures

My Plan for Tomorrow in Pictures:

1.Wake up, shower, eat an egg and toast and drink french pressed coffee.
2. First assist on a breast lumpectomy, an inguinal hernia, a needle localized breast biopsy, and a laparoscopic appendectomy.3. Tell you that I chose such a benign picture of an appendix because it reminded me of waves.
4. Bid farewell to Roseburg and head through the State of Jefferson, on my way to Southern California. Click the term "loony bin anti-government die hard extremists" to learn more.
5. Arrive in Montos de Los Altos de los Palos (or something like that), where Connie my Roseburgiean Landlordess has an Crazy Aunt who will put me up for the night. Only caveat is she smokes like a chimney and requires at least two bottles of Red Zinfandel per visitor. Something tells me she will have cats. Lots of cats.
6. Rest for the final leg of the 17 hour drive to San Diego. Where the waves will giveth, the skin will bronzeth, and the medicine will be internal. Whatever that means. See you there!

CA

The sickening irony of growth causing death. Cells out of control with multiplication causing subtraction of health.

I've seen it.
A cousin lost as a teenager, the fear of recurrence in the eyes of an imprisoned man. The metastasis to the liver shining bright on a CT scan. My mother finishing up her radiation treatment in Boston.

The phone call that you don't forget.
The scrambling through websites that it prompts.
The numbers, statistics, percentages flying at you like bullets.

Then more irony in the way we fight it. Chemicals and radiation used to fight something perhaps caused by the same. Intangible hope and prayers directed at all-too tangible cells.

The fight that it requires but the calm that it demands.

The way it hits you. And the reaction that collision sets off.

I'm proud of you Mom, et al.

Contradictions are Contraindicated

In the art of medicine, when something is contraindicated, it is a good idea to not give it, perform it, prescribe it, or do whatever you are not supposed to do with it. The "it" may be a drug, a procedure, or an otherwise benign substance or activity. We avoid contraindications like we avoid lighting ourselves on fire. Makes sense, right? I'd don't like being on fire. That's why babies don't get aspirin, viagra and nitroglycerin don't mix, and ummm....pregnancy and parsley are evil together.

In the art of politics, contradictions float around like oxygen molecules, inhaled and exhaled on a daily basis, without a care. A few:

• Government run health care would be so inefficient....but......it would be too good and put all the insurance companies out of business. Which one is it?

• Americans have plenty of access to health care (A.K.A Status Quo and the GWB "Just Go To an Emergency Room Plan")....but....if everybody gets insurance then our doctor's will be too busy! If "everything is fine" then why would stirring the pot, so to speak, stir up an *overwhelming* amount of people who need help? "Republicans opposed to sweeping reform say the health care system would be overwhelmed if nearly 50 million uninsured Americans are given coverage"---Associated Press
  

• This health care thing costs too much....but...$900 billion in Iraq and Afghanistan (resulting in 5,000+ U.S. deaths), is just fine.
  

• "Christian Right Largely Opposes Health Care Reform" .....but.....There's This.

Perhaps these contradictions should be contraindicated in a worthwhile discussion about health care. Pick your stance and stick too it. Disagree with your neighbor, that's OK. But don't change your argument with each new sound bite on the inflammatory morning talk show. Like giving a cigarette to an asthmatic, tossing around contradictions should be ill-advised.

It was only a matter of time before this blog made some inciting statements (not to be confused with insightful). I apologize, and will soon be back on track, reporting on life as a PA student. To smooth things over, I offer this Old-School Nintendo Game that we can all agree was pretty sweet. It is only Contraindicated in those with ADHD and Seizure Disorder.

Just One of Thousands

Once again, the 2.5 hour drive up to Portland from Roseburg is worth every cent, every ounce of gasoline. Amazing weekend in the city: From eating Moroccan food to getting beat by Audrey at tennis. From watching the above birds do their yearly migratory dance at sunset to seeing Weinland play a few blocks from our house.

Back south to Gallbladder Land. Next time I am going to keep heading south, until I hit the border of Old Mexico. Then I will go back north a few miles and plant myself within sight of the sea and start treating people with medicine, instead of just yanking body parts out of small holes.

CA

The sickening irony of growth causing death.
I've seen it.
A cousin lost as a teenager, the fear of recurrence in the eyes of an imprisoned man. The metastasis to the liver shining bright on a CT scan. My mother finishing up her radiation treatment in Boston.
The phone call that you don't forget.
The scrambling through websites that it prompts.
The numbers, statistics, percentages flying at you like bullets.

Then more irony in the way we fight it. Chemicals and radiation used to fight something perhaps caused by the same. Intangible hope and prayers directed at all-too tangible cells.

The fight that it requires but the calm that it demands.

The way it hits you. And the reaction that collision sets off.

I'm proud of you Mom, et al.

Four Thumbs Up

2 for Inglourious Basterds, Quentin Tarantino's new film, which I indulged in last night after getting off early from work. It was our anniversary, so I honored the event by watching a movie that she would never in a million years sit through. (See, this frees me up for a future chick flick, when we are reunited.)

2 for Obama's healthcare speech that just ended. Again, a slow day in the OR early allowed me to go to the library and stream it live on CNN. I hope you had a chance to watch it also.

The Do's and Don'ts of a Roseburg Surgery Rotation

Don't live with a crazy lady with 2 kids and an untrained dog in a messy house unless you really want to spend the entirety of your evenings in your weird room that is decorated with strange bear paraphernalia, which includes but is not limited to, a life size black bear dressed like a fisherman. Do make friends with the bear.

Do be prepared to nod and smile at the small talk in the break room, which generally revolves around comparing Obama to Hitler, adding up how many handguns one has (and losing count), or bashing people who recycle. Don't bring up health care reform.

Don't walk into the OR without your mask on. If people start waving in a circling motion around their mouth, with a disgusted and hateful look in their eyes, Do take that as a sign that you are missing something.

Do learn the proper anatomy terms, however Don't be surprised when the surgeon refers to the "Butt Case" we'll be doing at 9:30.

Don't blog on the net about the wrong-sided surgery that you witnessed a part of. Do remember to tell others about it in person, behind closed doors.

Don't expect a blog from me for a few days. I'm headed to the coast (via Portland) to spend the long weekend surfing with Audrey and Josh. Do enjoy your weekend. Do it now.

Perma-Change

In the middle of a rotation that won't last forever, like most things. Last weekend in Portland, Audrey and I went on a trail run in our beloved Forest Park. At the outset it seemed like summer still, with blue skies, yellow sun, and green leaves. The primary colors of summer. But in the depths of the shady park, there was change. The brown hue was creeping into the floor and walls of this windy hallway of a route. On some corners, near the dried up creeks, the decomposing leaves allowed a rich, musty air to hang in the nostrils until our fast-paced lungs could exchange it on the next uphill. The next morning we woke up to gray skies in Portland. The day after that it was September. And here I am contemplating Change.

On the drive back to Roseburg, I surfed the FM channels of the Toyota's radio. At one point I drove right into some airtime that was hosting all sorts of great Latin music. Rumba, Salsa, Afro-Cuban, Mambo....and I was soaking it up like a laparotomy sponge. But as my trajectory was southbound on Interstate 5, at a rate faster than most police officers would be comfortable with, I knew the rhythms were not going to last forever. And then, sure enough, before you could say "Tito Puente y su Orquesta", it was gone. Evaporated 15 minutes after it was born.

This rotation won't last either. Though shorter than a summer, and longer than a 4 minute Samba, at times it feels like both. At times, hours fly by, running from case to case. Other moments are stretched slowly out like an outgoing tide, like listening to the surgeon tell the 49 year old man that his metastatic colon cancer gives him less than 20% chance to still be alive in 5 years. In a few weeks, I will be a distant memory to this hospital and vice versa. I will be the new face elsewhere and a new town and a new state and will become my temporary home. You have to like the word "new" to survive this year.

Change is inevitable. You don't need a blog to tell you that. We see it in September, we hear it on the radio, we sense it in the mirror every morning. The question becomes how to interact with this change. For me, I prefer to trail run towards it, tap my hands on the steering wheel with it, pretend to know the words in Spanish for it and scrub in through it. I hope this finds you all interacting with change in your own personal way. Yours Truly, CD...

Mr. Tyrone Laces

Each morning, after passing through the hospital doors, I avoid the urge to take a left and follow the hallway that leads to the ER. I feel the pull, but fight it, and head straight to the belly of the hospital, the OR. Passing through a few more doors gets me to the inner sanctum: The Surgeon's Lounge, complete with leather wrap-around couches, a large flat screen TV with ESPN on, and donuts. I pause to watch SportsCenter's attempt at making pre-season football seem dramatic. Perhaps I scrounge some donut action. Then I continue a few more steps to grab scrubs, cap, mask, and shoe covers.

That's about where my freewill ends for the day. After that I am at the mercy of the surgeons, nurses, and staff. I hold things when I am told, I let go of things when I am told, I cut things where I am told, I sew things up in the manner that I am told, I follow surgeon's to the ICU when I am told, and I go to the cafeteria when I am told.

Actually for 10 minutes in the middle of each day, I am granted some more freewill in the form of a Salad Bar. I enjoy choosing which cherry tomatoes to plop next to the chosen carrots. I enjoy not choosing mushrooms, opting instead for chopped egg.....

Then it is back to reality. I am told when to stop eating and when to head back to the OR. I am even told when to be told.

So far I think I am doing a pretty good job of doing things when and how and where I am told. But is it a problem that it took me 20 minutes to tie my shoes this morning because I sat there staring at them for 19 minutes waiting for somebody to tell me to tie them?

Horse vs. Wasp

"Can you come to my place and ride my horse once a week while I recover from this surgery?" asks the rancher with diverticulitis and a fistula (connection) from his colon to his bladder, causing frequent infections and air to be expelled from his penis.

"I also have a beautiful daughter, but she's as ornery as a wet wasp," he says trying to sweeten the deal to the young (appearing) PA student who has to take his wedding ring off for surgeries.

I almost take him up on the non-ornery horse riding half of this offer, as I picture myself saddled up, trotting around the Oregon foothills with a piece of straw dangling from my lower lip, or maybe a Marlboro. I could trade in the scrubs for Levi's, the frigid operating room for the August sun.

Then he starts talking about hay bales, heavy lifting, and general barnyard type work, and I decide to just let the ornery daughter get her hands dirty for once and help her poor rancher-dad out.

Croakies, stat.

OK enough about the destination. Despite my assessment of this town and my unending search for the perfect place, this rotation is actually about surgery.

Lots of gallbladders, hernias, breast biopsies, and colonoscopies. First part of the week it was a lot of watching. The HR people were not convinced that my negative TB test from May meant that I didn't have tuberculosis. They wanted to feel no induration for themselves. Once they did, I was allowed to "touch patients", as the lady put it. That's good, I thought. While shadowing this whole time, I have been breathing on them. But never mind that TB is transmitted by air droplets. As long as I don't "touch" them.

Once I was allowed to scrub in, TB-free, things got more interesting. I basically act as the first assist on all surgeries. I stand across from the surgeon and hold retractors, suction fluid, and cut knots. Only once did I contaminate the entire sterile field and the patient by having my completely unsterile safety glasses drop off my head onto the patient and the drape. I followed this with a short expletive and a thorough apology. I was glad to not get kicked out of the OR and they told me they would get me some croakies.

Other fun moments:

• Holding a gallbladder in my hand
• Totally sucking at the subcuticular suture
• Watching the surgeon sort through small intestine, like so many sausages
• Eating PB and crackers for lunch as I chase the surgeon through 13 cases in 12 hours
• Having today off, after a really fun weekend with Audrey, exploring all the places from the previous post (a trip that may deserve it's own dedicated post, and may be found soon at chipandaudrey.blogspot.com)

Rose Colored Lenses

To catch up a bit on the last few weeks of bloglessness:

• I finished my prison rotation with mixed feelings. Overall very good experience to have so much autonomy, have a fun classmate to share the ups and downs (and the 1.5 hour drive) with, and great to be living at home and seeing Audrey every day. But for the most part, Tom said it best: "Its time to move on, time to get going ..."
• Had a week of "class" which was a nice vacation. (Stayed up past 8:30 pm on more than one occasion!)
  
• Onward to Roseburg and a rotation in surgery. This town of about 20,000 has potential written all over it. A nice historic downtown, a river running through it, free concerts in the park (I drank beer with the surgeon and an anesthesiologist as we listened to Susan Tedeschi), and a veritable hotbed of recreation opportunities in the nearby Upqua River corridor. For example....Not to mention the whitewater kayaking, an 80-mile hiking trail, proximity to the Pacific Ocean, and the arid climate (compared to soggy Portland.)
  

This place is destined for an Outside magazine exposé entitled "America's Top 10 Secret Towns You Should Move to Now". You know the article. We've all read them. Where is the next cool place? It's too late for Telluride, CO. It's over for Burlington, VT. Bellingham, WA? That's so 7 years ago. Authors dig deep these days: Salida, CO, New Paltz, NY, Boone, NC....Enter Roseburg.

But something is just not right. Like many of the obscure locales, there is a reason why it remains a secret. The economy here seems like a sinking ship. Vacant storefronts outnumber the operating businesses. A Friday evening in the historic town center reveals an eerie silence. An aging population may keep the hospital busy but the overall vibe here is one of decay. The new subdivision I reside in has halted construction. The developer brought his cows down to the pasture that was supposed to house new homes. The coffee shop is only open Monday through Friday. Time will tell if this town can truly become an Outside Magazine posterchild. Or will remain the impoverished Douglas County Seat, with bad schools, no jobs, and vacant storefronts? Either way, the river, the mountains and the lakes will be here when you arrive.

Scratch Marks

Been slow on the blog. 106 degree afternoons and hot laptops don’t mix. 1 week left of this rotation. Don’t really type in full sentences any more. Interesting habit. Lazy. Hot.

Amidst the average, have been a few noteworthy patients in the last few days:

On intake history and physical exam find large firm, mobile cyst-like protrusion under the skin of the dorsal aspect of el pene and the patient tells me, “es un mármol. Para las mujeres.” I wonder if that procedure is covered by insurance.

Photokeratitis vs. the ocular manifestations of the great masquerader, syphilis. I was like, really?

Due to a scheduling error, completing a sleep apnea work up on the wrong patient, in Spanish. Turns out that when you simply answer “sí” to every question, as my patient did, I could diagnose you with paroxysmal nocturnal dyspnea, when all you needed was your GERD meds renewed.

Frothy urine.

Hemochromatosis (diagnosed through trans-oceanic collaboration with the most famous PA-S in Norwegian-Hawaiian history)

Epididymitis vs. Spermatocele. I never thought I would actually perform the physical exam test known as transillumination of the scrotum. How wrong I was.

Time in prison is dwindling down. Scratch marks are approaching thirty.

Before Lunch

Long week of "chronic care" patients. Nothing exciting enough to jump up and down about. Nothing funny enough to laugh out loud about. Nothing depressing enough to vent about. Just a long week of HIV, Hep C, DM, HTN, chronic pain, and hypothyroidism. OK maybe a bit of subconscious venting there....

I went with the doctor to the special housing unit where patients are on lock down 22 hours a day, and can walk back and forth in a little kennel like structure for the other 2 hours. We practiced medicine in what seemed like a dusty closet. A musty concrete smell clouded the body odor. I could hear the showers down the hall from where I was seeing patients. The whole building echoed loudly with the sounds of guards and radios and showers. The orange of the inmates jumpsuit was a sharp contrast to the gray and white metal of the cells, the floors, and the handcuffs they wore throughout the exam.

Awareness of surroundings is critical in this environment. But this heightened attention creates a shifting of senses. The mindfulness leads to a sharpness. The background becomes just as important as what as in front of you. The ink scratch.. of the tattoo.. on the arm.. of the patient.. in the jumpsuit..on the table.. in the jail cell..with a window..to the outside..with it's blue sky....all individual pieces that make up the terrain that my senses navigate.

Then I went to lunch.

No sign of Bernie today, I guess they sent him to another FCI in North Carolina.
Release date: year 2139.

Had 3 patients today that were being released within the next 2 months. Through similar grins, each told me the exact number of days they had left.

27 yo with recent diagnosis of HIV will get out without an opportunistic infection, but with a rapidly dropping CD4 count.

44 yo with chronic Hepatits C will get out with only half the anti-viral treatment he needs. I doubt he is willing to stay for the remainder. I also doubt he will complete the treatment in Mexico, where this gringo plans on heading after his halfway house stay.

71 yo with hypertension, hyperlipidemia, and "a 50 year old wife waiting for me on the outside." His blood pressure is the last thing on his list of things to take care of when he heads to Portland in 23 days.

I/M

Most SOAP notes start with: 55 yo gentleman.... or 40 yo female....19 yo patient....or 23 yo man....a way to convey an image in the reader's mind, a quick identity for the patient. Sometimes other descriptors are added to enhance the image: well-appearing....pleasant.....morbidly obese.....Hispanic......Caucasian......you name it.

In prison, the doctors simply write I/M .

Inmate. That is what they are. That is the only image that they wish to convey and the only identity that they permit them to have.

I refuse and still write "patient" (gender is assumed in an all-male facility). A subtle difference, perhaps. Maybe just a shortcut they use to save a few key strokes. Or with the first word of the entire assessment, are they are setting the tone early? Maybe with three key strokes: I/M buys them the excuse they were looking for. The excuse to blow off a nagging symptom, to refuse a CT scan, to withhold a new medication. Maybe it is a reminder to them, the first thing they and future readers will see when they open the chart: Inmate, Inmate, Inmate.

I can't be sure. But for now, I'm writing "patient" not I/M, because it feels like that's why I am here. To help a patient. To not harm a patient. To listen to a patient.

(((((((My next post could easily be a rant about how I think it is absurd that the 50 million people without health insurance (and without a prison sentence) don't have anywhere close to the access to health care that these inmates, er, patients have. So before you label me a complete Hug-a-Thug, know that I am conflicted to say the least.)))))))))))

Black Hairy Tongue

	Apparently most people take a photo when they get Black Hairy Tongue.
	Judging by the hundreds available on Google Images. My patient lives in prison, where they don't have cameras. At least not the point-n-shoot type Plenty of surveillance cameras. None of which caught my guy's intermittent symptoms Better luck next time.