Category Archives: worry

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Balancing act

I am working at a site in the greater Seattle area, but I am not going to say where. Why? Two reasons. One is that the patient diversity is huge: the organization is organized to take care of low income, uninsured and immigrant patients. The second is that I am still trying to decide if the balance of the organization is working. It may be working but it might not be working for me.

I am at a large clinic, with primary care, dental, behavioral health, a nutritionist, a pharmacy and three in person translators. In any one day I will probably use translators for at least six languages. English, Spanish, Dari, Hindi, Punjabi, Arabic, French, Somali and sometimes languages that I have to look up the country because I don’t know where that language is spoken. The work is fast and furious.

The overall no show rate is 20%. This makes the day very unpredictable. It can be very very fast and busy with everyone showing up and then later there are three no shows in a row. I think that the no show rate has been less than 20% but on Tuesday it was more. However, everyone showed up in the morning and there was a hospital follow up that should have had 40 minutes and only had 20 and of course then we ran later. My lunch theoretically starts at 12 but I went to lunch at 12:50 and came back 6 minutes late, at 1:06. Then people no showed while I worked to finish off everything from the morning. It did feel a bit nuts.

We are using the electronic medical record EPIC. I find EPIC epically frustrating. It is “feature rich” which means it has too many ways to do things. If I ask someone how to record a phone call to a patient, it takes eight steps. A week later I have to do it again, I ask again, and the next person shows me a DIFFERENT set of eight steps. And there have to be at least eight ways to do anything, so it is very confusing. Also, the “home” page can be personalized to the extent that people look at my version (I have not personalized it much) and say, “Mine looks different. I don’t know how to do that on yours.”

Whew. So, how to cope with the fast furious unpredictable schedule? I am “precharting”. For this Tuesday, I spent 70 minutes going through the patient charts on Saturday. Then I may know why they are coming in, if they had a heart attack two weeks ago and are following up, if it is a well child check and the last one was two years ago, if there are outstanding issues like a elevated liver tests or they have not been in for their out of control diabetes for a year. Then, of course, some of them do not show up. It is so busy that all I feel when someone no shows is some relief, like a ray of sunlight in a dark forest. Ok, the person who was horribly sick and in the hospital for a week and had surgery, they really do need to follow up. But I cannot make them, no one can.

We have live translators, outside translators who come with the patient, family sometimes translates and two phone translation systems. Our live translators cover the following. One Spanish only, one Dari, Arabic and ?maybe Russian. A third language. The third does Hindi, Punjabi and something else. I can’t tell by language who is a recent immigrant or refugee or who is a citizen of the United States for thirty years.

The clinic system has high standards for care of an often vulnerable population. However, I have not decided if it falls into a statement by my grandfather: “The higher the ideals of an organization, the worse its’ human relations.” My job in Alamosa had very high ideals, but I was fifth senior doctor out of 15 in a mere two years. A burnout job. This one has three new doctors coming in soon. My training and assistance to learn EPIC has been sparse and not up to my standards. If the new doctors are treated the same way then this is a burnout job as well. This is a place that I could work in intermittently alternating with other places in the country, but only if it is balanced for both the patients and the physicians. The jury is still out, but there are many red flags. It is a six month job and I am two months in, so we shall see.

Hugs to everyone.

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For the Ragtag Daily Prompt: nuts.

The photograph is from Larrabee State Park this weekend. My daughter came out and saw many of her friends, stayed with me, and we camped for one night at Larrabee.

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Sad about the cows

The first photograph is Sol Duc. She is lying on my jacket to object to and obstruct me going to work. She has learned the new schedule, but things are a little different. In the three weeks we were gone, the night time temperatures have dropped into the 20s, so it is frozen outside. Yesterday it warmed to a high of 53 but not for long. It is dark in the morning and dark at night when I get home and we have not been walking with the harness and leash as much. Brrr, cold. We had a long walk yesterday at 10 am because it was my administrative day and I was caught up.

Sol Duc can’t find her pet toad any more. I think the toads have dug in for the winter and there are fewer and fewer insects. I think she is a bit bored. I’ve been building cardboard box puzzles for her, with the cat food ball inside. She has to roll the ball around to get the dry food to fall out. Maybe now she misses Elwha a bit, too. My work days are a bit long, leaving at 7:00 am and sometimes not home until 6:00 pm. Right now I have to drive to the other end of the valley.

The second picture is this morning’s sunrise. Gorgeous, yes? But that is the field across the street from us and that changed while we were gone too. They are building roads, all of the wild plants are gone, and it is staked all over and has large machines. And kitty corner, to the southwest, no more cows! The cows are gone! Are they inside for the winter or really gone? I think that they are really gone, because I see cows in other fields. The hay barn is still in use, but the cows have been moved. The city of Grand Junction is building and encroaching on the farms. We are right on the western edge of Grand Junction. No more early morning roosters, either.

I am not sure how to tie this to the Ragtag Daily Prompt, circular. Sol Duc is pretty circular when she curls up. The earth and the sky are circular. Emotions circle, happy to sad to surprised to worried and back. I am a little sad about the loss of the field and the cows, sigh, but happy Saturday to you.

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Pick one, delete two

I went through my blog this morning, picked a month two years ago, and deleted a bunch of photographs and the accompanying posts. More room! It is not a very fast process.

I am thinking about the Ragtag Daily Prompt today, hamfatter. It makes me think of Miss Piggy first. Don’t we all have a little bit of ham in us if we are in the right situation? Even if it’s just a dream or a daydream. Hamfatter also brings up ham and my inlaws. My son and daughter-in-law and daughter were all home for my birthday earlier this year. We also stopped at my daughter-in-law’s house, to pick my son up. Her parents heard it was my birthday and gave me a ham. How surprising and kind!

Yesterday I ordered prints of photographs to send to them, almost all with their daughter. She told me not to print any of the climbing gym or of the pets that her mother dislikes. Got it! I tried to pick ones that they will enjoy. It is a start of holiday gifts.

I am still having disaster nightmares, last night about my house. My house is far away right now and apparently my brain is worrying. I dreamed that there were clean baby clothes folded and piled all over the place in the upstairs bathroom, even on the commode. I took them off it and discovered that it was backed up. Then the walls dissolved and I realized with horror that there was water flooding through them! Then I woke up. Not a fun dream and no, there are not clean baby clothes in the upstairs bathroom. I think it is a combination of being far away and the coming administrative change. In some states it is illegal for a physician to discuss abortion. Will vaccines be next? And the most abortions are the spontaneous ones, where the pregnancy ends and passes. We call that a miscarriage but it is also called a spontaneous abortion. I wonder if those are illegal too.

I dress a bit more formally for work then at home. Maybe there is a bit of hamfatter there, too, entering the role of doctor.

I took the photograph in 2007.

For the Ragtag Daily Prompt: hamfatter.

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Wait

I came close but no cigar
I want a mind that I can love
hand holding mine in the car
I send a quiet prayer above
Love of nature, kind to friends
not afraid of their own dark
Lust to learn until their end
willing to risk to build an ark
Curious but not controlling
Not addicted to booze or drugs
Intense at times and others strolling
Opinions, laughter and lots of hugs
My heart open yet I don’t faint
I think I am waiting for a saint

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I wrote the poem yesterday, but I have used up my memory in wordpress and now I need to go through and delete things. Any advice, Martha? I know you did it. It seems that I have to delete the post and the photograph, or is that not true? Advice welcomed.

I search my photographs for gloves and it comes up with two: foxgloves! Well, strictly speaking, that is a form of glove, right?

For the Ragtag Daily Prompt: glove.

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Wee timorous cowering beastie

No, not a mouse. But the lizards are timid too. They do not want to engage and they leave very quickly. These one is fairly large, a foot long, so she posed for a photograph. Let’s crop it.

The next one is going for camouflage and is really quite brilliant at it. I like the tiny blue dots.

I also catch sight of small things scurrying out of my path hiking. Also lizards, 3 or 4 cm long, and very fast.

Today I go back to the first clinic I worked at here. I am feeling mildly timid myself. Stage fright? I can’t sing a song that I know, because I don’t choose the patients. They show up.

I took these photographs on the Palisade loop trial, in July. The lizards like it.

For the Ragtag Daily Prompt: timid.

I left out sleeket.

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Bolster my courage

I am having nightmares. About clinic. Yesterday I bolstered my courage and sat down to write my dream out. What are my dreams trying to tell me? Should I extend my contract or not?

I dream that in clinic I have a male patient with his wife in the room. He is very dramatic, saying, “I am so ill, help me, help me.” He says, “I am on quercetin. You have to help me.”

He won’t tell me what his symptoms are, so I respond to what he says: “Who prescribed quercetin? What is your diagnosis?”

“Oh, you don’t want to help me,” he says. His wife just watches.

“Do you have pain somewhere? Any chest pain? Any abdominal pain? Any pain anywhere?”

“No, no, you don’t understand!” he says, “You aren’t listening!”

“I am trying to help you,” I say. “Can we reschedule you for a longer visit?” This is one of the impossible 20 minute ones. Honestly, he doesn’t look like he’s in pain. I do a quick listen to heart and lungs and feel his abdomen.

“No, I need to be in the hospital, I can’t go home!”

“I can’t put you in the hospital without a diagnosis, but we can move you to the emergency room.” Of course, the ER won’t be happy about this.

I leave the room and call the ER. The ER doctor is understandably grumpy, since I have no idea what this is about and am suspecting a psychiatric cause. “Urine drug screen,” I say. “He doesn’t smell drunk. I do not think it’s meth withdrawal.” “Make sure you do a note,” snarls the ER doctor. Good luck, since he won’t answer any questions. “How behind am I?” I ask the nurse. She just rolls her eyes. I probably have at least four or five more on the schedule. I come back to the room. Now two preteens are in the room, looking in the drawers and taking things out. Their parents do nothing to stop them.

“Please sit down now!” I say. “Put that down!”

The teens sullenly comply. The father is moaning. He has the prescriber on his cell phone. He hands it to me. I introduce myself. “What is your diagnosis?” I say. “Why is he on quercetin?” The person at the other end mumbles. “Excuse me, what did you say?” He’s gone. I say to the mother, “Please take the children to the waiting room. Sir, are you requesting that we call 911?” It would be a call saying man moaning, no idea what he’s on about. Vitals are normal, he denies chest pressure or pain, he doesn’t have an acute abdomen, his oxygen level is fine, no fast heart rate, no fever. Drama.

I wake up, thinking that I may have to call 911 to get the wife and kids out and I have to have someone monitor him while I see other patients and we just don’t have enough staff and I am ready to just cancel the rest of the afternoon. If I were in a hospital, I could call security, but we are a satellite small clinic.

So… what the heck is THIS dream about? And do we really get patients like this? Yes, but not often and I haven’t had any like this here. I think it’s funny that this dream has so much detail, down to the supplement that the man is taking as well as the clinic room. I usually work in room 1 and 2, but this was in room 5.

To be continued.

For the Ragtag Daily Prompt: bolster.



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Honey and the ants again

The next two times Honey feels the ants biting from the inside feeling are also on obstetrics.

Both times it is a VBAC. Vaginal birth after cesarean. The woman has has a cesarean section in the past and is trying for a vaginal birth.

Both times, Honey gets the biting ant feeling. There doesn’t seem to be anything wrong with the woman in labor, the nurse is relaxed, the fetal heart monitor looks ok.

With the first one it is the younger male obstetrician who is on call. He is a big man. He sits and peruses the monitor strip outside the room, taking his time. “There were some decelerations back here, but the heart rate looks fine now. Do you really want me to consult?”

Honey can’t stand still, the ants feel so bad. She tries to sound professional and calm. “Yes, this is a VBAC. I would like you to go in and meet her.” She is trying not to shoo him towards the room. He shrugs and gets up, not quite slouching towards the room, Honey trying not to jump up and down in impatience behind him.

In the room, he introduces himself. Again, Honey has not told her patient. The obstetrician says, “Dr. B. asked me to stop by since you have previously had a cesarean section, but everything looks fine.” Two minutes later she and the nurse and the obstetrician all alert as the the fetal heart rate monitor chirp slows, dropping from the 120s down to 60. THERE IT IS! thinks Honey. It stays down, they have the mother roll on her side and pop oxygen on her. It comes back up, but that is that. Off to the operating room. Again, they don’t have to do a crash cesarean. This time it is not clear what was wrong, but everything comes out well.

On the third round, it is the older male obstetrician. He looks at the strip and is calm and goes right into the room. He introduces himself and everything looks fine. Honey is wanting to dance from foot to foot from the ants. Again the fetal heart rate drops, right as the obstetrician gets up to leave the room. The nurse has the woman roll to her side and adds oxygen. The calm obstetrician gives Honey a look and has the nurse get the surgical consent. The heart rate is back up and off they go.

Honey wonders. Ants? Little voices? She knows that we all pick up information from body language and information that is not conscious. That could be a scientific explanation. Information that is not quite conscious. Honey decides that she really does not care what the ants are. When those voices speak, she listens. Who cares what it is, as long as it works.

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What is the word? “Fictionalized”, from fallible, friable memory.

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Honey and the ants

Honey is in her second year working. She escapes clinic because she has a labor patient. In the daytime! Not on a weekend or at 2 am! Hooray!

She has to hang out, because this is baby number five, so it could come really really fast. Everything is cool. The mom has more experience than she does, nearly. Well, Honey has done more deliveries, but has only had one baby.

Honey starts to feel itchy. Agitated. It’s not skin at all. Something is bugging her. She goes in and out of the room. The nurse seems totally unperturbed, but Honey feels like ants are attacking her, from the inside. She goes out the room and studies the rhythm strip, the baby’s heartbeat. There is a printer feeding out in the central nurses station.

Screw it, thinks Honey. I make look stupid, but I don’t care. She calls the obstetrician. It’s the woman who is on. Honey is a Family Medicine physician. They are in rival clinics. “Hi,” says Honey, identifying herself, “I need a consult on this woman.” She reels off the medical details, Gravida 5, Para 4, all vaginal deliveries, no complications. “I just feel like there is something wrong. There isn’t anything really bad on the strip. But I need you to come.”

The woman obstetrician comes. She sits and studies the heartbeat strip. Honey still feels like ants are biting from inside. The OB puts the strip down. “There is nothing on this that would get you in trouble. But you’re right: something is wrong. Come on.”

Honey has not told the patient that she’s calling the obstetrician. The patient might be annoyed. They go in the room. The obstetrician introduces herself. “Dr. B called me to consult. We have a bad feeling. We want to do a cesarean section.” Honey is sure the patient will say no. She is wrong.

“Me too,” says the patient. “Do it.”

They do the paperwork and move quickly to the operating room. Not a crash cesarean, not an emergency, so spinal anesthesia, not general. Honey assists.

They are in. There it is. The umbilical cord is wrapped four times around the infant’s neck. It has not tightened down. Honey has goosebumps as they gently unwrap the cord and do the delivery. The baby is fine, no problems, apgars of 9 and 9. They complete the surgery, mom is doing fine too. Honey still feels rattled but the ants have gone away.

The mother is relieved when she wakes, glad they did it, glad to hold her fifth child. The obstetrician is in charge of post operative and Honey is managing the baby. They don’t really talk about it, everyone acts as if it’s all routine. If the cord had tightened down, everything still could have been ok, but it would be a crash cesarean section, general anesthesia, more risky for everyone. It could also have not been ok.

Honey is relieved to go home, adrenaline draining away and leaving her very very tired.

Honey decides that she will listen to those ants, that feeling, any time it shows up.

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Based on a true story, at least, on memories, that are unreliable. Aren’t they?

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Mind

Facing a wall or lying in bed
breathe slow: four seconds in
one two three four
four seconds out
one two three four
keeping count

or facing a wall sitting
on a zafu, bell rings to start
how can forty minutes be so long?
fall asleep and body weaves
waking me up OH don’t hit the wall
adrenaline then slithering down
towards sleep again

zen mind, blank mind?
my mind wanders off again and again
what is for dinner? grocery list?
that annoying thing or person
at school or work
the mind busy as a squirrel
burying nuts and digging them back up

bring the mind back again
again again again
to the breath the wall letting go
of this well trodden mind trail
only to have the mind wander off
down another: this with briars
and falling into a pond
that has ice and cold

back shake like a dog
shake it off
focus on the breath the wall again
vivid multicolor cats
with paisley and stripes and spots
there is the BELL
forty minutes

Bow to the wall
and stretch
get up
ready zafu for the next time
meditation
mind

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Written today for the Ragtag Daily Prompt: blank.

The translation that I originally learned is here.

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Driving Lily

I was driven yesterday. I have an ill friend. She is currently in a “rehab”, aka “nursing home”, in Sequim. I drive 40 minutes to be with her at an hour appointment. Afterwards we check in at the nursing home and then I drive her back to her house, 40 minutes again. That is where Lily is. Lily is her cat. My friend was in the hospital for six days and now the “rehab” for two weeks. My friend wants to go home. Lily is miserable. She misses her person and hisses and swipes at me. I was driven to take my friend to see her cat.

Lily let me pet her yesterday because I brought her person home. However, the whole thing was a near disaster. My friend has been trying to get stronger, but she is not stronger. She is weaker. She has three steps into her house. We were there for about three hours. She sat to wash the cat’s bowl in the kitchen sink and Lily was very very happy to be near her. My friend was then tired enough that we had real difficulty getting her out of the house and back in the car. I used a bath stool to let her stop and sit about every four feet. She was using a walker, but could barely walk. She sat in the doorway of the house and talked about crawling. However, those muscles in your upper legs? Those are some of the biggest muscles in the body, and if you can barely walk, scooting or crawling is not feasible either.

We made it to the car without having to call an ambulance. I’m pretty strong for my age and size, but I’m not strong enough to carry her alone.

Poor Lily. I don’t think I dare try to get her in a cat carrier and she’d probably cry all the way driving and anyhow, the nursing home would need a shot record.

Lily will have to put up with my care for now.

For the Ragtag Daily Prompt: driven.

I am not my friend’s doctor, I am just a friend.