I Am So Very Very Tired

Yesterday I saw 19 patients in 5 hours.  That's 15 minutes per patient, with just a few seconds to breathe between appointments.  I examined an EKG with 2mm ST depression in leads I, V3 and V4 in a man with only one patent coronary artery (documented on cardiac catheterization in 2008), but didn't have an old EKG for comparison to help figure out whether this was chronic or acute ischemia.  I diagnosed new-onset atrial fibrillation and congestive heart failure in the same patient.  I told countless parents that their children had viral respiratory infections that did not need antibiotics.  I removed several pesky moles and a misbehaving IUD.  This whirlwind of activity makes the day go by quickly, but it doesn't allow any time for reflection.  My streak of back-to-back appointments ended only because I got called to the hospital to admit a new patient: an 84-yr-old male who was seeing his PMD for a routine diabetes check when he described a 3-day history of epigastric pain radiating to his left arm, but refused to wait for the results of his cardiac enzymes to see if he was having a heart attack.  It was only when he got home, slipped on ice, and broke his hip, that he ended up getting hospitalized.  [His troponin peaked at 15, by the way!  A definite heart attack-worthy level!]

Best Christmas Present Ever

It's a combination ice scraper/snow brush in lightweight aluminum, courtesy of tiny tots Jimmy & Lucy.  Huge improvement over the slotted spoon I used in Fairbanks.  

Jimmy: Is this what you wanted your whole life?

Me: Yes!

Thanks, J & L!

Invasion of the Tiny Tots

A few of Dr & Mrs H's tiny blond and blue-eyed grandchildren are visiting for the holidays.  Lucy, age 2, and her brother Jimmy, age 4 are providing hours of endless entertainment

Lucy: Need EGGS!  Need more eggs RIGHT NOW!  Those are MY crumbs! [running around the living room with a red plastic bucket on her head]
Jimmy: I slept for 40 hours.  Can I have a bandaid? [Scooby Doo bandaids are a particularly hot commodity in this household right now, and the kids keep making up excuses for needing more bandaids]

After I was done with clinic and hospital patients for the day, I prepared the dough for my notoriously decadent cinnamon buns with lots of brown sugar, butter, and cinnamon.  They never turn out exactly the same because I don't really use a recipe.  I let the dough rise overnight, and this morning I could hear the children running through the house at 5 am like a herd of stampeding elephants.  I went to the kitchen to check on the bread dough which had almost tripled in size.

The kids were very curious about the dough, so I set them up at the kitchen island, each with their own ball of dough, and taught them how to flatten the dough, spread the cinnamon & brown sugar filling on top, roll it into a log, and divide the log into little buns with cinnamon swirls.  They each got their own tiny baking pan and their own private stash of child-size cinnamon buns...which they refused to share with anyone...including their own father.

Cases du Jour

17-month-old boy with a small patch of erythema at the base of his penis.  There is warmth, but no induration or fluctuance.  He seems uncomfortable during recent diaper changes.  Upon closer inspection, there is a circumferential crease-like indentation on the penile shaft.  Theory: a hair tourniquet possibly causing microscopic breaks in the skin, letting bacteria in, and leading to the development of cellulitis?  After a short course of keflex, the erythema has disappeared and everything is back to normal.

40-yr-old male with branch retinal vein occlusion of the L eye (his only symptom was a 2-month history of blurry vision) diagnosed by an optometrist who sent him to clinic for a full systemic disease workup, since most patients with this condition are over the age of 65.  This affable man is 30 lbs overweight, drinks 6 to 10 beers daily, has smoked 2 packs of cigarettes a day for the past 20 years, and has an elevated blood pressure of 148/100.  I think it's kind of obvious why he had the equivalent of a stroke in his eye.  It's no surprise when his fasting cholesterol turns out to be sky high, and I send him home with a prescription for morning aspirin and a bedtime statin after politely reading him the riot act about modifying diet & exercise and cutting down on tobacco & alcohol use.

P.S. They still use demerol here!  For migraine headaches!  I've never seen demerol used outside of Season 3 Episode 5 of Mad Men when Betty Draper was in labor and became dreamily hallucinogenic after receiving a shot of demerol for pain...

The Queen of Freak Accidents Goes Cross Country Skiing

I'm not exaggerating when I call myself the Queen of Freak Accidents.
Example 1: I wake up from an excellent night's sleep and as I place my foot on the floor, I somehow hit an errant toothpick at such a bizarre angle that it halfway impales my big toe
Example 2: I open the freezer door and a can of frozen orange juice falls directly onto my ankle with enough force to create a 2 cm laceration

Being such a natural born klutz, the idea of going skiing seems like an egregious tempting of fate.  [The only time I ever skied was on the front lawn of a psychiatric hospital for adolescents where I was an undergraduate volunteer].  But Dr H & his wife have such a lovely collection of old-fashioned wooden skis, and there's a beautiful ski park nearby in the Okanogan National Forest, and they have promised there will be no head trauma or broken bones.  So I venture out with Dr H in gorgeous 29 degree weather, and the cross country ski trails are freshly groomed, and the snow is perfect.  Turns out that I did develop some semblance of balance and ability to shift weight during my secret past history of ice skating (which is another story in itself)...after about 20 minutes, I was coordinating the skis and the ski poles reasonably well, and while I did experience a few near-falls, I did not crack my skull or fracture my femur.

Now I can practice skiing in the yard, where I recently spotted a proliferation of deer tracks.  Once in a while, in early morning,  you might glimpse a few deer nibbling on something near the driveway.  When they see humans, they leap gracefully over the fence and disappear into the forest...

 

Appearing This Week In Clinic

1. A very sweet-natured 15-yr-old blond basketball player who came in with a sore throat, swollen anterior cervical lymphadenopathy, fatigue, and an erythematous maculopapular rash: positive for mono!  Sadly, there is no medication for this viral infection, and she will have to refrain from contact sports for 6 to 8 weeks to decrease the risk of her spleen rupturing.

2. A woman who slipped on ice and hurt her R middle finger: her distal interphalangeal joint (the joint closest to the fingernail), will not flex at all.  She has a flexor tendon injury & needs to see a hand surgeon for tendon repair before the damage becomes permanent.  This is also known as a "jersey finger" because the injury is commonly seen in football, when players grab the jersey of an opponent who wrenches away from them, causing hyperextension of the fingers.

3. A family of 4 children who literally have dirt in their ears: their mother wanted to make sure they didn't have ear infections.  My nurse tells me the family is very impoverished, and they live up in the mountains with no running water or electricity.

4. An elderly lady who fell on an outstretched hand and broke her triquetrum (one of the tiny bones of the wrist): she somehow ended up with an enormously heavy short arm cast and came in to complain that her arm was hurting more since the cast was applied.  I removed her cast and replaced it with a dainty, more lady-like wrist splint to keep her wrist immobilized for another couple of weeks.

5. Strangers who ask for candy: And by candy, I mean anything in the DEA Schedule II Controlled Substances group, which consists mainly of narcotic pain medications.  I am alarmed by the sheer volume of patients requesting opiates and consuming them nonchalantly like candy.
Acutely fractured ribs: definitely painful enough to need opiates like vicodin or percocet
Fractured ribs 7 weeks ago: should have healed by now
Depression: emotional pain does not resolve with opiates
I'm allergic to advil, tylenol, aleve, gabapentin, toradol and tramadol: spoken like a true narcotic seeker

Mist in the Mountains

Everything in the mountains was shrouded in mist when we went scouting for a suitable Christmas tree:

Mrs H usually does a preemptive sweep of the property in late fall and ties red ribbons on evergreens that look promising.  Dr H goes out in mid-December, assesses the beribboned candidates, then uses a hand saw to liberate the winner from its roots (if you look closely, you can see Dr H behind the tree with his saw, and Cedar the dog resting quietly in the background; the cat followed us too, but she's very adept at avoiding paparazzi):

Dr H drags the winning evergreen home

The tree is set up in the downstairs living room, where there's plenty of room for the treetop to extend beyond the second floor:

The Perks of Small Town Living

I am ensconced in the tiny town of Tonasket, population 995 [or 996 if you count me] located along the eastern bank of the Okanogan River, approximately 20 miles south of the Canadian border.  It's the land of apple orchards and cattle ranches, and the perks of small town living are as follows:

1. There are no furnished apartments available, so you get to stay with one of the physicians and his family in their lovely home in the mountains that looks like a rustic bed & breakfast inn:

2. The clinic, hospital and nursing home are all less than 50 paces apart
3. A patient whose ingrown toenail you removed announces loudly to everyone in the local grocery store that you cured him
4. You open your exam room door to greet a pleasantly demented elderly woman who exclaims, "Look, it's a pretty girl!" when she sees you
5. The clinic holiday party features a white elephant gift exchange in which most of the presents are 70 proof, and your door prize is...gin!

6. You get your picture in the newspaper, just for showing up to work:

5 Seconds in Seattle

Din Tai Fung is a famous restaurant originating in Taipei that specializes in xiao long bao.  The restaurant has several chains in Asia, but only one chain in the U.S. until quite recently, when the newest branch opened in Bellevue, WA.

Xiao long bao, colloquially known as soup dumplings, are traditionally filled with pork. The meat filling is wrapped, along with a gelatinized broth, in a thin stretchy dough and then steamed. The heat from steaming melts the gelatin into liquid broth, producing dumplings that seem to magically envelop hot soup.  The best way to approach the soup dumpling is to make a small hole in the dough to let the broth cool down before taking the first bite.

  

At both of the Din Tai Fung branches in the U.S. there is a large window in the kitchen through which you can see staff working in a rapid assembly line to produce dumplings.  One person stretches the dough out into a long rope; the next person divides the rope of dough into individual pieces that are weighed to ensure the size is uniform:

Next in the assembly line, a worker flattens the individual pieces of dough into circles with a wooden roller. Then another person places meat filling and gelatinized broth onto the circles of dough:

In the final sequence, the last worker neatly twists the edges of dough together to close up the dumpling and sends it to the steamer:

This is where I chose to go in the 5 seconds I was able to spend in the Seattle area before flying over the Cascade Mountains to my next locum tenens position in northeastern Washington state.  Delicious!               

Farewell to Fairbanks

Folks, it's time to leave the tundra.  Turns out that Captain D is not getting deployed after all, so an extra physician is no longer needed in the clinic.  Here's one last view of the hospital at sunset (3:15 pm!) and the intriguing sculpture in the center of the roundabout:  

The lovely fields of snow behind the hospital seen on a rare sunny afternoon:

My last view of Fairbanks from the airplane:

We flew over the Alaska Range which includes Mt McKinley (known here as Denali, the highest mountain in North America, with an elevation of 20,320 ft) just as the tiniest glimmer of sunrise was beginning:

The silhouette of the snow-capped range became more defined as the sunlight began to manifest itself:

And suddenly, just like that, the Puget Sound was peeking out from beneath the clouds:

Science Experiments in the Sub-Arctic

This thin coating of powdery white stuff on my car window is not snow.  It's precipitate from ice fog:

Today I learned that at 36 degrees below zero, frost can form on your eyelashes if you stay outdoors for more than 5 minutes:

Your own exhaled breath is your worst enemy--the surrounding air is already saturated and unable to absorb the extra moisture, so your breath forms tiny ice crystals as soon as it leaves your airway.  I discovered that if I exhale onto my hair, I can totally frost the tips:

Yes, that spiky white mess is my hair.  With frost on it.  

When the High Temp of the Day is -16 Degrees

We're back to our regular winter programming, with sparkly snow and that familiar sub-zero chill that makes it difficult to be outdoors for more than 15 minutes at a time before your fingers, toes and nose start feeling mildly frostbitten.  I spent  part of the weekend working in the ED, where I ran my own little fast track section for visits that really weren't emergencies at all: sore throat, cough, pinkeye, oral thrush, STD scare.  The ED clinicians use a nifty prescription medication dispensing machine after hours when the outpatient pharmacy is closed.  The genius dispenser looks almost exactly like this candy vending machine:

You order the prescription medication of your choice (nystatin suspension, azithromycin, triamcinolone, etc) on the computer.  A prescription label is printed out, and the nurse puts in a password that allows the machine to release the medication so it can be labeled and given to the patient.  Sometimes the medication gets stuck and you have to bang on the dispenser and yell at it a little, like a real live vending machine.

Knit 1, Purl 2

Friends, a true miracle has occurred:  I have actually taught myself to knit by reading a book.  It is very difficult to learn a complex 3-dimensional procedure by interpreting words & photographs from a 2-dimensional page, but it has somehow happened.   True, I'm still using acrylic practice yarn, my cables get a little jacked up, and every now and then I accidentally add or lose a stitch, but I am now my very own one-woman sweatshop.  Would anyone like to place an order for a hat, scarf, or (if I'm feeling ambitious) mittens?  Specify size, color and yarn type. Anyone...?  Otherwise, it's going to be a very loooong winter (and as Jerry Lewis says, idle feet are the devil's toenails!)

Aftermath

During the day, it continues to rain; then at night the temperature drops and ice starts to form.  There has been so much rain that water is accumulating on some roadways.  Most parking lots are a messy amalgam of slush, ice, and puddles the size of small ponds:

The Fairbanks North Borough superintendent finally decided to close all the schools late yesterday morning, after 5 school buses slid off the road and got stuck in ditches.  Apparently the children of Fairbanks haven't missed a school day since 2003 when there was a massive ice storm.  

The clinic is still open for acute appointments.  Who is risking life & limb to seek medical treatment in such hazardous driving conditions?  A mother bringing her 2-1/2 yr-old daughter in for vaccinations & a well child check that was due at 18 months.  A 19-yr-old woman with an acne break out, 3 weeks away from her wedding.  A 27-year-old woman who wants her IUD removed "because my husband says he can feel the IUD" with his ultra-sensitive penis during intercourse "and the IUD strings are poking inside his pee hole".  Don't get me started on how this is utterly physically impossible because the IUD is in the uterus and the penis can't go through the cervix into the uterus, and how even a board-certified urologist would have trouble getting the soft paragard IUD strings to thread through the penile urethra.

Freezing Rain

Freezing rain doesn't actually fall from the sky in an already-frozen state.  Raindrops are super-cooled while passing through a layer of gelid air just hundreds of feet above the surface, then freeze on impact after falling, forming a thin ice glaze as multiple drops accumulate.  This makes for hazardous driving conditions.  Today's unseasonably warm weather (low 30s) is rare; the last time Fairbanks had rainfall instead of snowfall in November was in 1936!

My car this morning was enveloped entirely in an opaque ice glaze accented with indentations formed by continuous pelting from raindrops.  It looked like an avant garde glass sculpture.  The temperature was hovering at just below freezing as I gingerly pulled the car out of the parking lot and started the treacherous commute to work.  The roads were extremely slippery, as if someone had gone over every inch with a Zamboni.  I'm pretty sure I was driving more slowly than all your grandmothers combined.  The walkway in front of the hospital might as well have been a skating rink; several of us slipped and nearly fell more than once.  I really should have worn ice skates to work.

Museum of the North

When I was a kid, my father enjoyed recounting tales of his own childhood fortitude.  "When I was your age," he would say, leaning back in his chair, "I walked [insert ridiculous # of miles] to school in the wintertime".  Well, Dad, today I walked 4 miles through a pseudo-blizzard for a round trip from my apartment to the University of Alaska, just so I could visit the Museum of the North.

The Fairbanks campus, established in 1917, was the first branch of the University of Alaska.  World-reknowned research is conducted here in the fields of Arctic biology, Arctic engineering, geophysics, supercomputing and aboriginal studies. The Museum of the North is located on the aptly-named Yukon Drive, and the snow was piling up rapidly as I approached the building:

It's a bit of an architectural wonder, with its asymmetrical shaping and specialized climate-control exhibition areas that house 1.4 million artifacts and specimens:

I especially enjoyed the exhibit on Alaskan Native crafts which displayed astoundingly intricate beadwork in the form of collars, bibs, pouches, and slippers:

I would totally wear this Yup'ik dance headdress (made from cloth, felt, seed beads and wolf & wolverine fur) and even these Yup'ik men's dancing gloves (made from leather, sealskin, seal fur and sinew):

 

There was a wonderful display of spirit masks (with part human/part animal faces, worn during ceremonial dances as an appeal to the spirit of prey animals) made from a variety of materials.  The one on the right is an Inupiat (King Island) maskette made from walrus ivory, mammoth ivory, baleen and feathers:

And there were delicate patterned baskets woven from grass, and a wonderful display on the ulu (an Inuit all-purpose knife traditionally used by women) made from steel, copper, brass and bone and used for skinning & cleaning animals, chopping food, cutting children's hair, and trimming blocks of snow and ice for igloo-building:

I could certainly use an ulu right now, to give myself a much- needed haircut...

The Crazies Are Coming Out of the Woodwork

A 55-yr-old woman tells me she was sitting in church on Sunday when she suddenly felt pain and "chills in my vagina".  I'm not sure what she means, and she doesn't know either.  All she knows is that her "pee smells bad".  Ironically, she is wearing a gallon of cologne and the fumes are making me woozy.  I quickly perform a pelvic exam before her cologne knocks me out completely, and there is nothing out of the ordinary.  Her wet mount, KOH prep, urinalysis, and cervical swab for chlamydia & gonorrhea are all stone cold normal.  Maybe having chills in your vagina is not such a terrible thing after all.

A waif-ish 32-yr-old woman comes in and spends 20 minutes complaining about frequent headaches that don't respond to ibuprofen.  She is vague about her symptoms, and all the medications I mention (triptans, beta-blockers, neuroleptics) she thinks she's already tried without relief.  She doesn't have medical records from her former neurologist.  "I had percocet once," she says coyly, "and it was too strong."  She asks for tylenol #3 (with codeine), "just until my medical records arrive."  Against my better judgment, I give her a limited prescription for 10 tablets with no refills.  Two hours later, she returns to clinic pouting, led by her grim-faced husband who is dressed in army fatigues and combat boots.  Turns out she's been in & out of treatment for an addiction to prescription narcotics & benzos for the past 4 years, but none of this is in her medical chart.  Needless to say, she'll be returning to treatment as soon as possible.

Sometimes I get a more satisfying case that makes up for the crazies, like the 10-yr-old girl with recurring muscle spasms in her left trapezius.  She had been seen in February and given a trigger point injection which provided good relief for several months.  She had full range of motion and normal strength in her shoulders & arms, but I was disturbed by a subtle asymmetry: her left shoulder was slightly higher than her right; and her left scapula was just a hair more prominent than the right.  She had been told that this was due to "stress".  I ordered a series of plain films which revealed mild scoliosis manifested by a teeny 11.9 degree levocurvature of her thoracic spine.

I wonder if I'll ever get used to having 20-minute appointment slots. It rarely ever seems like adequate time to spend with each patient, especially when it also encompasses the time it takes for the medical assistant to call the patient from the waiting room, take vital signs, and review allergies and medications.  By the time the patient is ready to be seen,  I'm lucky if there are 7 minutes left in the appointment slot.  It only works if it's a relatively straightforward medical problem, or if the patient can give an awesomely concise synopsis: "I'm a 19-yr-old G0P0 with a history of chlamydia, continuing to have unprotected sex, here for evaluation of crampy low abdominal pain with unusual vaginal discharge, s/p an exploratory laparotomy for what turned out to be severe pelvic inflammatory disease with Fitz-Hugh-Curtis syndrome 3 months ago"...[I really did see that patient!  But without the neat synopsis]

The Acronyms Are Driving Me Crazy

Every day I get memos in my military email account peppered with acronyms I'm not familiar with.  DMHRSi?  NCOIC?  TCON? ERD? I need some sort of acronym secret decoder ring to understand my email memos.  Even the faucet handles at the clinic are etched with acronyms: HW for hot water, CW for cold water:

Sub-Zero

Like clockwork, now that it's mid-November, sub-zero weather has arrived in Fairbanks.  Tonight the temperature dips down to -5, and tomorrow we have -20 degrees to look forward to.
How long does it take hot water splashed onto the windshield to freeze?  Less than two seconds.  Not. Kidding.
Ice fog: Fact or Fiction?  Ice fog develops when warm water vapor (from car exhaust, exhaled breath, etc) meets super-cold air, causing microscopic ice crystals to form in the air.  The frigid air can't absorb these ice crystals which congregate to form a dense cloud.  When it dips down to -30 degrees, I'll be sure to run outside just to exhale and watch my breath form a tiny cloud of ice fog that doesn't dissipate.
Does wet hair freeze when you go outdoors in sub-zero weather? I'm not brave enough to perform this experiment.
How short are the days? Today we had 6 hours 16 minutes of daylight, and each day gets progressively condensed by 7 minutes.  By winter solstice on December 21, daylight will only last for 3 hours 42 minutes [Please, sir, may I have more vitamin D?]

The Land of Aurora Borealis

It was an All-Asian night at the Aurora Borealis Lodge: just me, two visitors from Los Angeles, two from San Francisco, and our affable host Mok & his family.  The Lodge is 20 miles north of Fairbanks, on Cleary Summit (elevation 2000 ft), on a hill overlooking a beautiful forest, with a spacious viewing deck facing northward.  When we arrived at 10:30 pm, the sky was already glimmering with faint patches of aurora radiating modestly.  Over the course of the next 3-1/2 hours, we experienced an astounding display of auroral forms.  I've seen photographs of the northern lights, but still images can't convey the amazing dynamic nature of the phenomenon.  The greenish-white light morphed from a swirling plume to a billowing tower to a glowing arc across the sky, then back to faint patches with tiny delicate rays.  The light appeared white when viewed with the naked eye, but it took on a phosphorescent greenish hue when photographed at high shutter speed with a 10-second exposure.  My low-tech camera couldn't capture the images properly; I was envious of the overnight guests from Japan who had scurried out from their accommodations armed with tripods and SLR cameras with wide-angle lenses.  Here's a series of aurora borealis video clips that I cribbed from the University of Alaska museum:

The aurora borealis is best viewed on clear nights with minimal moonlight when the level of geomagnetic activity is elevated.  Activity is measured by the Kp index which ranges from 0 (no activity) to 9 (extremely high activity).  The greater your latitude, the less geomagnetic activity is required for the aurora to be visible.  The optimal location to view the aurora borealis is within the circumferential band that extends from 60 degrees to 70 degrees magnetic latitude, known as the auroral oval:

When the level of geomagnetic activity increases, the auroral oval starts extending southward, and the northern lights become visible at latitudes below 60 degrees.  There are entire websites dedicated to predicting when auroral activity reaches levels high enough to be seen.   Fairbanks, at the magnetic latitude of 64 degrees, only requires a Kp index of 1 for aurora-watching.  Seattle, at the magnetic latitude of 52.7 degrees, would need a Kp index of 7.  And Mexico City, at the magnetic latitude of 29.1, would need a Kp index of 9+++++++++

Where All the Girls Have PCOS

I haven't been here very long, but I've already seen 9 young women with polycystic ovarian syndrome.  Many have the classic symptoms of irregular menses with anovulatory cycles and hyperandrogenism manifested by acne and male pattern hair distribution on the upper lip/chin & linea alba/periumbilical region; some even have the characteristic ovaries with multiple tiny cysts.  One thing they all have in common is their desire to become pregnant; most of these ladies are between the ages of 19 and 23 and newly married.  Seeing 9 versions of the same problem is like being in some kind of bizarre Medical Twilight Zone.  I found myself prescribing clomiphene for the first time in an attempt to induce ovulation in a 22-year-old with normal FSH (follicle-stimulating hormone) levels and no symptoms of premature ovarian failure; she had been using an ovulation kit every month and was able to document that the last time she ovulated was 12 months ago!

The Irrepressible Urge to Buy Stuff

Something about the cold of winter and the desire to nest fosters an irrepressible urge to buy stuff.  My total time here will be less than 10 weeks, but I somehow ended up with a box of 45 tall kitchen trash bags and 6 rolls of paper towels.  I don't know how to knit, but I seem to have procured an entire set of bamboo size 7 knitting needles, circular needles, double-pointed needles AND a 5.5 mm crochet hook.  Witness my newly-purchased arsenal of thermoses:

Why would you need more than one thermos, one might ask.  One I use for coffee or tea; the other is a food thermos which is spectacular for transporting soup to work.  So far I've made a hearty split pea soup and a surprisingly lovely miso soup with tofu & toasted nori.
The thermoses also come in handy for those special moments when you really need hot water: for instance, when winter elements conspire to encase your car trunk hinges in ice so that your trunk is completely frozen shut.  Because if you're trapped in your frozen-shut trunk without 2 thermoses full of hot water, this trunk release cable will not help you: