Nights at St. Charles

   Just finished five night shifts at St. Charles.   I like working nights, once I'm in the same time zone, which always takes a couple days to adjust.  The hospital is quieter, the pace less frantic, and often there are a few minutes here and there to get horizontal.   I laid down on the window seat in the hospitalist office, since the call room was in some far-off corner away from the action.  The big picture windows brought in a lot of cold, but a friendly nurse gave me a couple blankets, toasty from the blanket warmer.   You're on your own at night...most specialists don't want to get out of bed, though they're usually willing to talk on the phone.   And you hope the three daytime docs tied up all the loose ends on their patients so you don't have to.   The pace was steady, and the Emergency Room was crowded a couple nights this week, which usually means plenty of business for me.  No one knows why the number of patients fluctuates so much from night to night.
    As a regional referral center for all of eastern Oregon, St. Charles has a "transfer center", which pages the nocturnist hospitalist about possible transfers, usually very sick patients.  It's pretty exciting to be managing the care of a really sick patient over the phone with another doctor at a tiny rural hospital hours away.   I had a midnight call from a doc in Burns who wanted transfer an elderly semi-comatose quadriplegic woman with pneumonia and sepsis.   But after he told me the story, I asked him to do a few things to stabilize her before the three hour road trip.  Due to the weather air transport was not available.  She had a very high serum potassium (6.7) and a very low serum sodium (115) with lowish blood pressure, so I asked him to give hydrocortisone, since this could indicate adrenal crisis.   I also asked him to check blood gases--even though her oxygen saturation was okay:  turned out her carbon dioxide level was high, so she needed BiPap, if not intubation.  He told me she did not have a fever, but a further check, inspired by the mention of adrenal crisis, showed she was hypothermic, with a rectal temp of 90.  So she was covered with a Bair Hugger, a warming blanket with circulating hot air, and given warm IV fluids.   (I always thought Bair Hugger was spelled "Bear Hugger".)   We discussed antibiotic choice--their miniture hospital didn't have the one I wanted, so he substituted another.   The woman finally arrived at the end of my shift, but I had her admission orders all written and waiting, so the ICU team could get right to work.   Her doc called a couple days later to inquire about her condition, and say thanks for the help.  I congratulated him on putting in that central line, which he hadn't done in years, but did successfully in this big pinch.
    The morning after my last night, I signed out to a new group of hospitalists I hadn't met before.  One arrived a little early, and started telling me about local politics.  I knew of three hospitalists who were planning to leave, mostly women who were excellent doctors, but couldn't juggle the twelve hour rotating shifts with having young children at home.  But now I heard two of the male doctors were leaving too.   It turns out Bend Memorial Clinic, the big multispecialty clinic in town, had hired their own hospitalists, which decreased the work available for the local ICU intensivists.  The intensivists, in turn, decided they wanted a "closed" ICU so only they could work in the ICU, excluding the hospitalists.  (And here I had been trying to protect the sleep of the intensivist by managing that patient from Burns through the night...even gave him time to take a shower  in the morning...my hospitalists told me not to bother in the future.)   The arrival of the BMC hospital group (whose medical director suggested I call him about working there in the future), also decreased the census of my Sound Inpatient Physicians hospitalist group, but SIP planned to make up the difference by doing all the medical work for the local psychiatric unit, Sageview.  There was also disgruntlement over salaries and management.   Every hospitalist program I've worked in (this is #5) has had politics, and usually locum tenens positions (like mine) are needed during such times of upheaval.   My plan is just to enjoy the work, and try not to get wrapped up in the politics.  It's hard to see good people struggle with these issues when their energy is better focused on patient care.
      One of the "benefits" of being a referral center is seeing unusual or interesting cases.   I admitted a young man with hypokalemic periodic paralysis.  His serum potassium was 1.6 and he could barely move.  I had never seen anyone with this diagnosis before, and had to look it up online on UpToDate so find out how fast I could replenish his potassium.   He was discharged the next day, so I guess my orders did the job.  
    I'm also struck by how much alcoholism there is here.   I haven't seen many patients admitted with chest pain from cocaine, as in southern Delaware, but here there have been a lot of alcoholics in need of detox, and suicidal drug overdoses, or both.   Perhaps having a psychiatric facility here changes the mix seen in this emergency room, but I suspect Bend's being especially hard hit by the recent economy meltdown has increased the amount of alcoholism.   The unemployment rate here is especially high.   The real estate market bubble was especially large, with housing very overbuilt, and one of the most overpriced markets in the country.  Apparently the population of Bend has shrunk 30% in the aftermath of that bubble bursting.  There are lots of people down on their luck, if they even stayed in town.   It's no wonder I could get this nice two bedroom apt for 3 months for only $850/month.   But now that winter is here...cold and dark, with barely nine hours of light each day, the rate of alcoholism is worse than ever.  
    So I finished my stretch of nights, got a little sleep, and headed to Portland to see a couple friends before my sister and I head south to visit our other sister outside Sacramento for Thanksgiving.   The road check showed it was snowing heavily in the mountains with chains required, so I took the hour longer route north to the Columbia River Gorge, then west to Portland.   There was a little snow, but not enough to need chains.  And I always enjoy driving through the Columbia River Scenic Area, even when the sky is dark with clouds.   But the winding roads reminded me to be sure to take this trip back to Bend during daylight hours.   When the weather is stormy, it's very dark at night out in these lightly populated areas.

Beach Workparty with Parrot

     I'm sure we're all sore and achy today after our three day marathon wood floor installation at our family beach house in Gleneden Beach.  We laid the groundwork over the last couple weeks:   hauled old carpet to the landfill, purchased the Genesis red oak engineered wood flooring and underlayment at Home Depot, bought a jamb saw and brought tools from homes in the valley.    It was slow going at first as we learned how to do it.  We started in the family room, and finished it on Friday.   Saturday we floored the two old bedrooms, which Karen had painted just before.  And Sunday we barely finished the living room and kitchen before it was time for everyone to head home to be ready for their regular jobs on Monday morning.   800 square feet and five rooms by five people in three days.  By the time the project was finished, we had become a finely tuned team, and had developed individual roles that functioned well.   Go Lyles-Kreitlow Team!
     My son, Bryan was our sawyer, doing most of the cuts requested by the folks on the ground, with a jamb saw, a circular saw, and the second day, we bought a table saw.   Bryan's wife, Charlotte, and their friend, Sarah became expert at the actual installation, using a rubber mallet, elbow grease and spacers to position the boards correctly.  My sister, Karen and I, were the support team.  Karen painted the two old bedrooms prior to the floor team moving in.  She and I laid most of the underlayment, I nailed down most of the floor molding.  We all developed a new appreciation for knee pads.  Bryan and Charlotte brought their rollerblading knee pads, and I got an inexpensive pair of styrofoam pads.  Our knees still feel bruised, but not as bad as they would have without.  We are all very pleased with the beauty of the new floor and the way it transforms the house and even makes it smell better!  Bryan made a short video tour of our new floors, which I've posted on my facebook page.
     We had time to share good food, drink, and play together too.   Bryan and Charlotte made something they called "Irish Car Bombs" with Guinness, Irish Cream and whiskey.  Sarah, who made Bryan and Charlotte's wedding cake, has been experimenting with making raw cakes.  She made a yummy pumpkin spice raw cake with fruit leather fall leaf cutouts on the creamy frosting.  Charlotte brought Chana Masala she had made, and Bryan whipped up some pumpkin spice bread french toast one morning.    Karen brought her parrot, Junior, who rides around on her shoulders.  We had some corn chips with our hummus at lunch, and Junior finally talked:   "want a cracker!"   He can also make chicken sounds, and supposedly can say "Good Morning" and "Okay, bye-bye".   Junior is housebroken--sits on the kitchen faucet and responds to the command, "Hurry up, go poop", and he will take pieces of food Mama Bird Karen holds in her mouth.   I wouldn't trust that sharp beak near my lips, but they trust each other.   
    It's Monday morning, and the beach house is pretty quiet with everyone gone.  With the roar of the surf and the heavy mist, it's been great sleeping weather.  I finally roused myself from bed to make a trip to the local landfill and Goodwill to clean up some of the clutter from the beach house.  Now I'm sitting at Beachtown Coffee internet cafe in Lincoln City, enjoying some hot chocolate, before I load up the leftover flooring and head back to Eugene to get my refund.   I'll stop in Newport on the way to schedule installation of a new fireplace insert for the beach house (the old cast iron woodstove there is cracked and no longer safe).   Looks like Santiam Pass is clear, so then I'll head on over the mountains back to Bend, since I have to exchange the rental car there tomorrow.   I've been in Oregon a month now, and glad we've finished the main work project (besides hospital work) I had planned for my time here.   And doing it as a family project we can all enjoy made it all the better.

Over the mountains and to the Beach

    As I left Bend early Tuesday morning, corn snow was spitting here and there, and a dark cloud loomed over the Cascades.  The snow line looked to be about 3000 ft, and as I climbed out of Sisters to Santiam Pass, quarter size fluffy flakes started falling.  There were no cars coming east, and only a couple tracks going west on Route 20.   I was glad I'd left early.  Don't want to have to chain up a rental car--really wish they would provide studded snows.  Santiam Pass was  supposedly clearer than crossing over Mt. Hood, according to http://www.tripcheck.com/, and it's the shorter route to the Willamette Valley, though usually has worse road conditions.   I was relieved to come out of the snow zone just past Detroit Lake, and heard later they got 5-7 inches in the Cascades that night.   Crossing the mountains this winter without studded tires is going to be a challenge.

   Once on I-5 travelling was easy.  I zipped up to Portland to pick up some furnishings for Bryan and Charlotte at Ikea near the Portland Airport, crossed town to my sister's house to pick up some used window blinds for them, then kept going west to my old favorite, Thai Roses, in Beaverton for lunch (Spicy Eggplant with Thai Basil).  Then headed down 217 to I-5 towards Springfield.  As the sun was dipping below the black clouds over the Coast Range on my right, there was an intense double rainbow over the fields on my left.  The rainbows made the full arc and moved with me most of my way down the Willamette Valley.  I could see both ends of the rainbows--no pots of gold, just sheep passing through.

   In Springfield, I loaded up half the engineered wood flooring I had bought the week before (no Home Depots on the central Oregon coast.) and maxed out the rented SUV's cargo capacity.   Bryan and I had a nice dinner at Eugene's North Bank Pub...wild mushrooms/Havarti grilled cheese for me with a glass of McMenamin's own Pinot Noir.  We talked about his plans for grad school online in Data Base Management.  Then I slept in the cat- free shed turned into a guesthouse in their backyard...very cozy with rain pattering all night long.   Feels like camping cuz the bathroom's in the main house and I'm on an air mattress on the ground.  I wore my sweatpants and ski cap with my flannel nightgown for sleep that night.

   I drove the flooring payload to the beach house today, pulled off the baseboard molding, primed some water spots to try to suppress any mold, so we're all ready for installation this weekend.    Over at the beach, the surf was heavy and at high tide the water came all the way up to the riprap and stairs.    The beach was covered in seafoam meringue, and big spindrifts blew off the tops of the breakers.  My dad used to call them zephyrs.   I don't know why the beach is so narrow in the winter and so wide in the summer--must have something to do with the violence of the breakers.   A man and a women drowned off the South Jetty of Yaquina Bay today--why would they be out there on a day like this?    For lunch I went to Mo's for a bowl of clam chowder.   There were lots of logs in the bay, and no Harbor Seals to be seen.   I drove back to Springfield in time for dinner with Bryan and Charlotte.   We went to "Off the Waffle"...nothing like that in Delaware or IHOP.  Charlotte and I had the BMB--Bacon Maple Syrup Basil with Havarti on a Liege waffle.  Delish.   It's a treat to try such interesting restaurants....and there's a whole list of culinary adventures waiting here.   Tomorrow I'll take the other half of the flooring down to the beach so we can install it all this weekend.

   Nice to be done with my second week of work at St. Charles.  We finished up with a two and half hour training session on billing and coding following my 11 hour day.   Medicare requires us to count how many bullet points  in the history, physical and review of systems (ROS).  Gotta have 20 ROS bullet points if you're going to bill for a complex visit.   It's crazy making.  Wish the Electronic Medical Record was more helpful for counting all the parts and translating it into a billing code so I didn't have to be paranoid about Medicare "Fraud and Abuse" and treble damages.  I just want to take care of patients, and not worry about this administrative nightmare.    When I return to Bend next week, I'm going to make a template so I can just check things off like the E.R docs, cuz I just can't seem to remember it all when I'm dictating notes.   Sigh.  They're going to be auditing our charts now for accurate billing and coding.  This problem just won't go away.

   Time to watch the "This Old House" video online about installation of floating wood floors, then off to bed to rest my aching bones.   I'm not accustomed to this much physical labor, that's for sure!

Back for Week 2 at St. Charles

     Well, this is really a working vacation.  I get to spend every other week seeing friends and family in Portland, Springfield and Gleneden Beach, but the alternate weeks I'm working hard as a hospitalist at St. Charles Medical Center here in Bend.   It's the major referral center east of the Cascades in Oregon, so we get patients sent in from a lot of small towns.   My first week here, I was impressed with the interesting problems I saw--things we probably would have referred from rural Delaware to the  mega-medical center Mecca two hours away.   A couple patients stand out in my memory.  One was a middle-age man who suddenly became confused, agitated and even violent.  He had just returned from a hunting trip a couple days before, happened to work immunizing horses and counting mosquitoes for a county vector control department.  He had a bit of a fever.  The outlying small hospital had already done a spinal tap to rule out meningitis, though he didn't have a stiff neck.   He had a few lymphocytes in his spinal fluid, indicating a viral infection.   With all those potential exposures, we checked labs for West Nile Virus (from mosquito counting, though his wife said the first frost where they came from had killed all the mosquitoes weeks ago), Western Equine Encephalitis (what they immunize horses for around here) and Lyme Disease (he had been on a hunting trip, and the weather had been warm during the day so maybe some ticks were still around).   We gave him antibiotics for the potential Lyme Disease, anti-virals for Herpes Simplex Encephalitis, and waited.   I was very surprised and excited that he improved so fast.  By the time I finished my first week, he was awake and talking, though still a little hazy in his thinking.   I heard a week later that none of our tests showed a diagnosis, but maybe convalescent antibody titres will tell.  And his brain function seemed back to normal.   I'm convinced our treatment saved him.

    Another patient referred from an outlying hospital was referred to us because we have an MRI available around the clock, and cardiac surgery too.  This elderly man had a stroke just 3 hours after an epidural steroid injection for low back pain.  The stroke work-up included an echocardiogram, which showed a probable vegetation on a heart valve, which can throw little clots (emboli) to the brain causing strokes.  Sure enough, the MRI of his brain showed multiple strokes, consistent with multiple emboli.  Shortly after he arrived, he spiked a fever, so I grabbed several blood cultures and started him on triple antibiotics for probable endocarditis.  The next morning his blood cultures came back positive, and he had a transesophageal echocardiogram to get a closer look at that heart valve vegetation.    Usually, with embolic strokes, we'd order blood thinners too, but I learned that infected emboli are likely to bleed, so anticoagulants shouldn't be used.   Fortunately for this man, his stroke symptoms improved rapidly and he did well.   In several weeks he will be reevaluated to see whether he needs heart valve surgery, and he'll need follow-up to tell whether he had an infection around his spinal cord at the site of the epidural injection.  Meanwhile he'll get 6 weeks of i.v. antibiotics.

   I've taken care of a young woman with advanced Crohn's Disease, a middle aged woman with perioorbital cellulitis, an elderly man with newly diagnosed metastatic renal cell cancer, another with bleeding esophageal varices (varicose veins) from alcoholic liver disease...some really sick people, and not everyone does well.   Then there are the usual problems...COPD exacerbations, dehydration, abdominal pain, low back pain, but they're all interesting because of the personalities of the people involved.  We just had a woman with an intractable cough, even gave her antibiotics for possible Whooping Cough, though the culture was still negative by the time we sent her home.  The respiratory therapist suggested we give a nebulizer treatment of inhaled lidocaine 1%.  It worked to relieve the terrible tickle in her throat and the paroxysms of coughing, and I learned a new trick of the trade!

  I started this blog with the story of a woman with abdominal pain on the flight from Chicago to Portland, resulting in an unplanned stop in Billings, Montana.   She called today, finally back home in California.  It turns out she had a bowel obstruction which required surgery in Billings.  She was very grateful that I "stood up for her" and asked them to land the plane, told me I looked like "an angel looking down on me".   I was delighted that she called to let me know how she was doing, and since she herself is a physical therapist, I talked shop a bit about the woeful lack of medical supplies on the plane, and how I thought it would be impossible to start an I.V. in the back of a plane with all the vibration and jostling.

   So, I'm still struggling to learn the computerized medical record system at the hospital.  My orientation didn't cover all the ins and outs of the system, so I'm always having to call for help.  This week is better than week 1, but I still feel the quality of my work isn't as good as it should be.  It takes a lot of patience and concentration to get it right, more than I have at times.  So it was nice after work tonight to connect with Rob on Skype.  What fun to see him talking to me.  It's tough to find a time when we're both available since we're both working 12 hours shifts in time zones 3 hours apart.  I'm still asleep when he leaves for work in the morning, and he's falling asleep about the time I come home from work.   6:30 pm in Oregon which is 9:30pm in Delaware seems to be a good time for a brief Skype.  Then I still have time to go lap swimming at Juniper Swim & Recreation Center before I hit the sack.  Had a good swim tonight, and now I'm sleepy, so will sign off for now.

My first day off: out and about in Bend

    There was an inch of snow on the ground this morning, but it didn't last long.  By afternoon it was completely gone and the sun was shining.  Still I know that means the mountain passes will be difficult to cross.   I called Avis to see whether they would provide tire chains?  "No, and you'll have to pay for any damage chains cause, and we don't provide studded tires either."  NyahNyahNyah.   Never mind that I rented the car in Portland and have to return it in mid-November in Bend, which is on the other side of the mountains.   So, I stuck the phone book in the car, and used it to find the Visitor Information Center and get some info.  She gave me an Oregon map with a website for road reports, recommended the hour longer drive to Portland by going up Rt 97 to the Columbia Gorge when it was snowing in the mountains, and told me about the Les Schwab Tire store a few blocks away where you could return unused tire chains at the end of the season (at any of their many tire stores in Oregon).   I headed over to pick up some chains--if I don't use them, my sister can return them in April for a refund.   And we might need them to go skiing. You're required to carry them in the passes when there's snow, or pay a hefty fine (and possibly skid or get stuck).   The salesman at Les Schwab asked me whether my owner's manual said chains were allowed on my rental car.  Unfortunately, there was no owner's manual in the glovebox, and he pointed out that many newer cars, even SUVs, don't have enough clearance for chains, but the law still requires them.   So, the receipt is in the glove compartment, and I'll probably take the longer route up to the Gorge to go to Portland just to play it safe.   I guess the car and tire companies are in cahoots:  you gotta buy studded tires for the wintertime.

After stocking up on maps and pamphlets, I drove up the Bend Parkway to the Cascade Village Shopping Center.  Bend is large enough to have all the major national chain stores.  First stop:  Trader Joe's, which we don't have in Delaware.  Got some good organic soups and fruit, and a couple indulgences too.  Then onto Home Depot to check out the wood flooring options for the beach house.  (We're ripping up old carpet this coming weekend, then putting down engineered wood floors two weekends after that.)  Then onto Michael's to see whether I could find some colorful posters for my white walls.  I didn't like any of the choices, so think I'll see whether there are any art supplies at the beach house to make my own.   Then I drove around awhile, learning the layout of the town, admiring the fall colors.   I finally found the Juniper Swim and Fitness Center run by the Bend Park and Rec Dept. and in the same quarter of town as my apartment.   I signed up for 3 months, and went back this afternoon for an hour's swim.  They have both a 50 meter outdoor pool which is under a bubble for the winter, and a 25 meter, warmer, indoor pool.   The outdoor pool was chilly at first, but just fine after a couple laps.  The swim team practices in one half of the pool, and open lap swimming was in the other half--I had a whole 25 meter lane to myself for most of my hour.   I'm gonna try to go everyday, now that I have a chlorine resistant suit that won't disintegrate so fast.  It feels so good!  I may even try to go to COMA, the Central Oregon Masters Aquatics, which is a coached workout for adults.  One of the hospitalists I met last week belongs to it, and it sounds like a lot of fun.  I have never been, and probably never will be a competitive swimmer, but I would like to improve my strokes.

Tonight I'm headed over to the McMenamin's St. Francis School solo to see Eat, Pray, Love, and sit on a couch in their movie theatre while eating dinner.  Rob and I stayed there when we traveled around Oregon after Bryan and Charlotte's Memorial Day wedding.   I've read the book, but think it'll be fun to see the movie.  Besides, I think the story sort of speaks to my solo adventure for these 3 months.   Tomorrow, I head to Portland to visit my sister, Karen, and have dinner with her and cousin Judy.   Then I plan to visit my friend Connie, before driving down to Springfield to pick up Bryan, Charlotte, and their friend who made their wedding cake so we can spend the weekend at the beach.   Life is good.

Colors and Peaks

I love the colors here.   The views out the hospital windows at St. Charles in Bend are scrumptious.  Deep blue of the mountains, soon to be white, and reds and yellows of autumn trees scattered about town.  The muted green of the Ponderosa Pines sets off the other colors.  There are lovely watercolors and pastels with saturated colors throughout the hospital, often reflecting the views outside--I often stop to admire them, and they help keep me oriented in the hospital maze.  Across a roof covered in river rock, a fellow is painting a mural of the exact same mountain peaks you can see around the corner of the building.   There's a sign 20 feet in front of the mural labelling both the real and the mural mountain peaks.  I'll be glad when the construction sign comes off the door, so I can go check out my hunches for which peak is which.   I know the Three Sisters, having backpacked to Obsidian Falls there long ago with my sister Joanne (remembering her shock when the campstove when up in flames, and I, as big sister, had to act like I knew what I was doing).  One nurse told me they used to call these mountains, "Faith, Hope, and Charity".  I remember as a preschooler drawing the "Three Sisters" when my Dad went on a business trip to the town of Sisters.  There were just three of us sisters then, since Sandra hadn't been born yet.  I guess she would have to be Three Fingered Jack, or one of the other peaks.  Of course, I was the North Sister, Karen was the Middle Sister, and Joanne the South Sister in my crayon drawings.

You can also see Mt Bachelor, which is just a few miles up Century Drive, and usually has enough snow for skiing by Thanksgiving.  Bend itself is about 3600 feet above sea level, which maybe explains why I felt a little breathless my first few days here.  The air is dry too...I'm drinking two large bottles of low cal lemonade a day, just so I don't feel so parched.  But I do enjoy the energizing feeling the blue skies give me.   Don't think I'd want to live in S.A.D. country again, like the other side of the mountains.  Winter blues are a real problem there with the dark rainy days.

For now, I can only admire the views, since my 11 hour work days keep me indoors, then it's dark by the time I get home.  But during my upcoming time off, I hope to drive up Pilot Butte, an extinct cinder cone right in Bend, and just a few blocks from the hospital.   And downtown Bend with miles of trails along the Deschutes River beckons too.  Gotta go there before the snow starts.

Wending my way to Bend

    First stop after landing in Portland was to visit old friends, Judy and Bob, and find that Judy's son and his girlfriend were visiting too.  We all had fun catching up, then headed downtown to have dinner at the food carts.  Portland has quite a few food carts set up in clusters around town, many run by grads from the Culinary Institutes who can't afford a real restaurant.   There's almost every ethnic food you can think of:  Egyptian, Korean, Northern Thai, etc.  I had a big plate of Pad Thai for Five Bucks.   The food carts have a reputation for good quality at reasonable prices and appear to be here to stay.  Who knew there were regional variations in Thai food?  Then we bar-hopped...a happy hour for Margueritas, and Higgins for a gooey chocolate concoction Bob and Judy discovered.   Then I headed over to my sister's house for the night.  We went to breakfast at my old favorite cafe, Marco's in Multnomah Village, before I headed out to drive to Bend.   I was feeling a little sentimental back in my home town...there are memories around every corner.

     Everyone recommended route 20 out of Salem as the fastest way over the mountains.  The vine maple was bright red, stunning against black lava fields.  I was shocked to see there had been a big forest fire near Santiam Pass, and stopped at the roadside interpretive sign to find out more about it.  Turns out it happened in 2003 (have I been gone that long?!).   Since they'd been suppressing brush fires, there had been a build up in underbrush fuel, so this forest fire had enough fuel to reach the crowns of the older trees.   Normally there are naturally occurring pine forest fires every 5-10 years caused by lightening, which keep the underbrush down, and create a natural parkland with widely spaced mature pine trees.   Fir forests have natural forest fires much less often.     It will take a long time to recover.   All the gray and black tree skeletons reminded me of the aftermath of the St. Helen's eruption, except these dead trees were still standing.

    In Bend, I found the Stonebriar apartment complex pretty easily, right on route 20, and only had to wait a few minutes for the manager to give me my keys and a tour.  The corporate furnishings folks had supplied basic furniture, dishes, and linens.  The electricity was hooked up, but cable access had to wait a day, and replacement of a broken modem before I could get online.  The apt is very nice, though it's all beige and white with bare walls.  I'm going to try to rustle up some colorful posters just to cheer it up a bit.  I made a trip to Costco and Safeway for a few groceries, and unpacked my three suitcases.  Still, the cupboards are mostly empty.  But it's more comfortable than a hotel, and should be a good space for friends and family to come visit, since there's an extra bedroom.

   This Monday I had my orientation at St. Charles Hospital, with several hours devoted to learning about their computer system.  I've had half the usual number of patients the last two days, but it takes me all day to see them because I'm so slow with the computer system.   The first day with patients, there were two I.T. people shadowing me, and the second day, I had to call the Help Desk numerous times.  It's going to take awhile to figure out this one.  Lots of nonintuitive, idiosyncrasies.  There's a steep learning curve, and even the old timers complain about it all the time...it will get better, but only to a point.  It's evolving.   St. Charles has McKesson, but everyone believes Cerner was/is better.

   Overall, I'm enjoying the new hospital, and it's fun to be a hospitalist again.  It's modern, with a very friendly welcoming staff, and beautiful views of the mountains.  I see Oregonians everywhere...in their blue jeans and plaid shirts.  I can see the Three Sisters, Broken Top, Three Fingered Jack and Mt. Bachelor.  I think another peak is Mt Washington, and I can also see Black Butte.   I bought a snow brush and ice scraper, and suspect I'll need to get some tire chains too.   It should be an exciting winter!  Soon I'll try out the Juniper Swim Center, and walk some trails along the Deschutes River in downtown Bend, though I'll probably drive to the top of Pilot Butte.  Meanwhile, I'm still catching up on sleep from jet lag and stocking the apartment.   Suspect I'll need to buy a few more warm clothes.   Luckily they don't seem to mind my wearing scrubs to work, and they don't take much suitcase space (though they're not very warm either!)

Off to a Bang in midair!

My three month adventure as a locum tenens doc in Bend, Oregon started off with a bang...before I even arrived.   Halfway between Chicago and Portland, the flight attendant asked, "Is there a doctor on the plane?"  I waved my hand, though not very vigorously.  She motioned me to come forward, and I had to turn my ear toward her to hear what it was about.  There was a woman 3 rows back who had terrible abdominal pain and was vomiting nonstop.  She asked me if I had a copy of my medical license with me, and when I assured her I did, we took the woman and her husband to the back of the plane.   I took a brief history...turns out she'd had bad pain when she boarded, but it had gotten worse, and now she couldn't stop vomiting.  She didn't have a fever, had no help from Pepcid, wasn't on any significant medication, bowels were working okay, and she had a previous appendectomy.   I tried to take her blood pressure and listen for bowel sounds, but couldn't hear a thing with my stethoscope due to the roar of the plane.  Finally I took her blood pressure by feeling her pulse begin as I deflated the cuff.  It was okay initially.  But the right side of her abdomen was quite tender.

So, they had me talk to the airline doctor on the ground by radio, and I said I thought she was safe to wait two hours until we landed in Portland.  But, the emergency medical supplies on the plane had nothing for pain beyond Tylenol, and nothing for nausea.   There weren't even any pillows or blankets on the plane!  There were supplies for an i.v., but I thought it would be impossible to start an i.v. with all the motion and vibration.   So I kept checking her blood pressure every 20 minutes or so.  And it started to go down, to the point her pulse was thready and she was feeling a little dizzy.   I insisted she lay down in the last row of seats and put her feet up.  Then I changed my mind...we really did need to divert the plane to land sooner.  I told the captain, who said he could have us on the ground in 30 minutes...in Billings, Montana!   It was pretty intense to make that decision which would make 200 people miss their connections.  The captain made it clear, it was my decision to make.

We landed in Billings, and there were no other planes in sight.  But there was an ambulance waiting.  They rolled a big ramp up to the back door of the plane, but we had to wait while the cabin depressurized before they could open the door.   I gave the first EMT a quick history, especially the concern about her falling blood pressure.   He came in and immediately started an i.v. while the woman was still lying on the back seats, while another EMT brought a collapsible stretcher aboard, after I stepped outside to clear other equipment from the ramp.  Soon they had her rolling out the door, while most of the passengers were standing up watching.  I slipped her husband a piece of paper with my cellphone number on it and asked him to let me know how it turned out.  The woman's father give me a big hug as he left...I smelled his aftershave the rest of the day.  After we landed in Portland, the flight attendant thanked me over the P.A. system, and I received a big round of applause from the passengers.

A couple days later, her husband called me from Billings...turns out she had a small bowel obstruction, probably due to scar tissue from the old appendectomy.  I had been thinking more about her gallbladder, but without an xray couldn't say for sure.  She'd been on a morphine drip for the first 2 days, then the pain relapsed when it was stopped.  They were worried she would need surgery.  

I know the flight attendants and the woman's family were grateful for my help, though the woman herself was annoyed at my frequent blood pressure checks and insistence that she lie down when she didn't want to....she was also unhappy when I didn't divert the plane immediately.   I was a little relieved when her dropping blood pressure made the decision clear...we couldn't wait for Portland.    I know it was an expensive decision.  The plane had to refill and recheck everything before we could take off again at an airport they usually didn't fly to.  They've got my name and license number now if they want to send me a flight voucher...I'd be happy with that, but I'm not holding my breath.   But, mostly I was happy to hear from the husband and know she was going to be all right eventually.