Thursday, May 17, 2007

Cascade Chaperone

A couple pictures taken during my afternoon of work as a chaperone on a 2nd grade field-trip.

Dr. Bedell has been as enthuiastic about teaching me how to successfully diagnose and manuveer through a Class 3 rapid as he has with teaching me how to sew up lacerations and perform a thorough work-up of a patient presenting with atypical chest pain. Bedell has the charm and knowledge of a rafting guide and the modesty and experience of a true outdoorsmen, all qualities which make him this great doc to work with, and for his patients. More than just concered with teaching me medicine, Bedell extends his obligations to introducing me to new life experiences. On the river and on the trails, he'll make up case scenairos of potential wilderness medical situations, even if only seemingly to disrupt the silence and monotony of a long hike. We'll hit up topics including high altitude sickness, contact dermatitis, giardia illness, tick and animal bites, traumatic c-spine and bone fractures, and lightining strikes-- real life stuff that interests me, but not necessarily what you get from reading textbooks or attending class. If Bedell thinks that there is more to gain from hiking to the summit of a local mountain than there is from a slow day spent in the clinic, he'll make sure that I've brought along snowshoes so that he can send me packing. The same is true for a day spent as a chaperone for an elementary school hike around the scenic Lake Cascade. Who'd have ever though I'd be riding in a boisterous yellow school bus packed full of second graders in the middle of Idaho? My boss' daughter had a school fieldtrip to Crown Point, and I was offered the opportunity to attend as a chaperone. Yes, there are certainly worse things in life than spending an afternoon under the sun, taking a pleasant stroll along a scenic lakeside trail with funny little school children.

Wednesday, May 16, 2007

Wilderness Medicine

Big Boss Bedell behind the captain's wheel

In rural Cascade, Idaho, you really get to see it all in a day, from the bedside to the riverside. This morning, Dr. Bedell and I were called in emergently before dawn to evaluate a patient for acute coronary syndrome-like chest pain. While this would not be something that unusual for a Cardiologist or Emergency medicine physician to see on the daily, any emergency room visit in Cascade brings excitment to an otherwise slow-moving country hospital. The beauty of family medicine lies in the breadth and diversity of patient encounters, leaving you to guess what you will see next. In a rural community hospital, where a "mass casualty" alert can potentially go into effect spontaneously given the dearth of local health care providers, we are always kept on alert, and forced to think quickly and act efficiently. Fortunately for the patient, normal EKG rhythm strips and non-elevated cardiac enzymes proved to be reassuring, allowing us to send her swiftly on her way, with a scheduled followup at the clinic in one week.

By sunrise, I was making post-partum rounds on recently laboring mothers, doing the typical stuff Ob/Gyns do, like assessing fundal heights and asking mothers if their bleeding has subsided, and if they've passed gas or had a BM yet. Switching gears between the different disciplines can be daunting, forcing me to focus hard on what I am actually assessing so as not to forget any pertinent questions to ask, or god forbid, to appear confused and stupid. After completing my postpartum check-ups, I transitioned from evaluating mothers to their products of conception, spending the rest of my mid-morning performing newborn exams on one day old infants. Transitioning into the role of a Pediatrician, I again, had to take on an entirely different approach, forced to abandon my practiced questioning skills for purely observational ones. While the little ones do not speak yet, they sure know how to kick, squirm, and cry, all signs of rebellion directed against the precipitous change from the warmly bouyant and nurturing environment of mother's womb to the cool and dry, mountainous environment of central Idaho. All of this change made more intense and less bearable by the cold steel rim of the sthethescope I have placed directly on their bare little chests.

By noontime, I was already at home, not just for a quick lunch, but to help Dr. Bedell inflate, load up, and strap down a 14 feet long raft to the platform of a trailer for shuttling down to the riverside. By 1 pm, we were thundering down the Cabarton stretch North fork of the Payette River, navigating through sets of rapids known to the locals as "Cocaine," and "Howard's plunge." I sat in the front of the raft, sipping on beers, soaking in all the warm sunny rays and the ice cold river water, reaping everything I could from life, not one bit envious of where my peers may be on an early Wednesday afternoon in the middle of May.

Sunday, May 13, 2007

The Gospel Hump

Taking a waterbreak midway into our hike on the second morning. I'm sitting rather comfortably, aside from being mildly dehydrated and achy from the toes up from the previous long day of hiking, and a night spent rehydrating on beers and sleeping on the ground.

A view from the tent. Taking a break from my Family Medicine book to scope out the scenery and Dr. Bedell.
Obsidian Stout, aka "Sid," the third member of our trip, posing for a pic at our private sandy river side campsite. The flow of the Salmon River was especially high and fast from the recent snowmelt, charging her way through the canyon. If only we had decided to bring the raft...
A view of the Idaho Centennial trail switchbacking its way up from our Salmon River campsite into the Gospel Hump Wilderness.

Wednesday, May 9, 2007

The Full Experience

For all the loan money I have invested into my medical education, I am finally beginning to cash in on the returns with a full hands-on medical training experience. While staying at the house of the doctor who is overseeing my Family medicine clerkship seemed at first like a terrible, "I must always be on my best behavior at all times," freedom restricting idea, I have come to realize that there couldn't possibly be a more complete "family" medicine experience.
Today, my morning began with a rude awakening, not from the alarm clock set for 7:00 am, but from the phone ringing at 5:45am to herald the news of a woman in full contracting labor (aka, we need a physician, promptly). I sprung out of bed, hair unkempt, mouth nasty tasting, sleepies still caked around my eyes, threw on a pair of scrubs, and met big boss Bedell in the hallway as instructed, "like Batman and Robin, should the phone happen to ring at night." Practicing medicine as the only family doc in town means that you are continuously committed to the care of your patients, be it morning or night, in the rain or shine. Rural medicine can transform unpredictably from a chill, laid back clinic day to a hectic "get your gloves and gown bloody, we've got lives to save" kind of day. My day began with the assistance in the delivery of a healthy 38 week old, small for gestational age infant, and didn't end until I had successfully performed an excisional skin biopsy of a possible melanoma, applied two Voler splints to probable distal arm fractures, sugar-tong splinted a man's compound wrist fracture/dislocation after unsuccessfully attempting to reduce his radius and ulna bones back into place from their "jagged bones protruding from skin" orientation, and performed two venipunctures to start up IV lines, meanwhile running back and forth from the clinic and ER to work-up scheduled clinic patients for pharyngitis, acute COPD exacerbation, recurrent yeast infection, and acute alcoholic intoxication, among other diagnoses.
To date, my apprenticeship in Family medicine has afforded me the opportunity to sew up lacerations, perform nerve blocks and steroid injections, surgically remove ingrown toenails, order labs and imaging tests, write prescriptions, verbally dictate notes for medical transcription, and most challengingly of all, to defend my clinical decisions with confidence and reason. Dr. Bedell makes me work responsibly hard and expects me to assume the full care of the patients that I see, including the initial work-up, deciding on which labs/tests to order, following-up on those tests, and deciding on a treatment plan of care. He allows me the chance to see his patients before he does and encourages me to justify my findings and assessment with confident reasoning. We'll spend a few moments talking over my treatment plan, at which time Bedell offers a few recommendations, then tells me to make the final call, including writing the prescriptions, filling out the imaging/lab order form, and proceeding with the plan of care. Whenever I remain unsure of my decisions or hint that I am still vacillating between two treatment plans, Bedell will respond by saying "I dont know man, he's your patient. You've gotta decide and tell the nurse what you want done. They're not going to listen to me. I've told them that you're calling all the shots." So it really forces me to be confident with my clinical decisions. When we go in together to see the patient together, Dr. Bedell is always saying stuff like "Andy decided to start you on this antibiotic" or "Andy has decided to order these tests for you," or 'Andy will give you a call this afternoon to inform you of the results of the tests he ordered," which always surprises me a little, but makes me feel like I am actually a part of the care.

Tuesday, May 8, 2007

Rural medicine

At the Cascade Medical Center, there is an Emergency Room where we see a lot of male Idahoans come in, because for one reason or another, they make a habit out of packing lots of sharp objects into their bags, downing multiple beers, and then hopping onto the back of a four wheeler. Men are known to be dumb, but when you give them the freedom to combine alcohol with the limitless outdoor pursuits of the provincial lifestyle, they become recklessly dumb. If we're not seeing the bloody man from the fourwheeler accident, then we're seeing the dude with the fishhook embedded deeply in his toe, who claims he has no idea why his toe hurts or looks so nasty and swollen, and reports that he has not been fishing for over 2 weeks. And then we see the unfortunately young tree loggers that come in with 10 inch lacerations from their backfiring chainsaws, asking if there is a Doctor that can "sew up my little cut." In just my short stay here, I have witnessed some hilariously dumb folks deep from the woods of Idaho, albeit hardy and tough. These guys present to the office looking awfully grimy and just plain down and dirty, with their clothing soiled and body all banged up, but they are grateful as hell, and smile reverently up at you as their miracle healer when you patch up their wounds.

Practicing primary care medicine in a rural community can be challenging, as the availability of resources for referal and access to high tech diagnostic tests and acute emergency care can be severely limiting. Sometimes, just getting the basic utility needs can present as a challenge. Dr. Bedell, the family doc I'm working with, performs scheduled upper GI endoscopies and colonoscopys every Thursday morning. As one of the only physicians in town, he pretty much does it all, just shy of major surgery. Last week, during the middle of his colonoscopy procedure, the power suddenly goes out through the entire hospital/clinic, leaving us to stand there in the silent dark, staring at a blank tv screen, holding what remained left of the four feet long black tube inserted 3/4 of the way up this dudes ass. I could only chuckle inwardly, meanwhile pondering the irony and likelihood ratio of something like this happening. I followed the lead of the attending physician and maintained my cool composure. Luckily for the patient, we were able to locate an alternative power source with the aid of an extension cord, thereby allowing us to finish the procedure and safely withdrawing the endoscope. And fortunately for us, the guy was not the least bit aware of our electrical malfunction, as he snoozed deeply through what was supposedly only a small dose of "conscious sedation." Now thats what I call rural medicine.