Billings, MT 1

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medical        *
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I'm beginning this on Saturday, 11/26. I've had a headache for much of the past 48 hours. It is located behind my eyes but not associated with nausea. Yesterday I broke out in a rash in areas typically affected by eczema. I've had similar but rare reactions in the past to drugs like Ibuprofen. So I'm trying to go without Ibuprofen for the present.

I have been using marijuana from time to time during the past week. Although I had acquired it to help with any nausea, it turns out to be surprisingly effective for pain. However, it very much limits what I can do. I don't trust my thinking when I'm stoned and I'm not able to write. Last night I used a small amount and sat with Jasmine to watch a mindless TV show.

The delivery system for the pot is a vaporizer. Rather than burning the drug in a pipe or cigarette, a small amount of hot air is passed over the material to extract the chemicals. There is no smoke, just a perfume-like white vapor that is much easier on the lungs than smoke.

I continue to use the treatments for gout, Uloric and Colchicine. I'm also taking 2 multivitamins, some Vitamin D, and omeprazole to reduce stomach acid production. I didn't use anything for sleep last night and I managed to get about 6 hours.

Wed...Nov 30

I really feel like shit. Not as bad as Thanksgiving, but bad enough this morning to think about bailing out of all this. I went to bed at 10 and took 2 percocette. Was up at 12 but felt fair. Slept for another hour and woke up this way with a headache, pain in my left and right chest. Sitting on the side of the bed was a very low moment and I found myself wondering why I wanted to keep doing this today. One of the things that I noticed is that I have begun to feel some obligation to keep writing as much as possible--at least long enough to get to what I think are the best parts of my life, rather than some of the stuff I've been trying to write my way through lately.

So I got to my computer and saw the emails from my sister, who is this amazing woman who found the energy to keep all of the siblings together and then turned it up a notch and adopted this great child, Elizabeth, who shares something in common with my mother and my wife, Jasmine.

Jasmine and Elizabeth are Asian beauties. My mother was the 5th born in her family. At the age of five or six, my mother was told that every fifth child born in the world was Chinese. (I guess this was the demographic factoid of 1926 condensed for easy inclusion in a Hearst headline.) Given this knowledge, my mother began checking the mirror on a regular basis waiting for the facial changes to occur. Had she been able to look ahead to pictures of a daughter-in-law and a grandchild, she might have checked more often and for a longer period of time.

Kirk was the one-year old on our fabulous camping trip of 1957. He was the movie star because there were film clips of him being knocked down by a wave and being dragged out in the undertow. He was nice enough to provide some details about Thanksgiving and his wife, Claudia, sent the picture of the some of the technologically savvy members of our clan.

Some of the Sohr Clan: Thanksgiving 2011

My sister is Suzanne, whose many talents have kept the siblings close, generally celebrates major feast days by entering her kitchen at 5 A.M. and leaving it at 10 P.M. The above are recent recipients of her love. The names in parenthesis are members of the prior generation with genetic responsibility.  Back Row from left: Nick and Alex (Dana), Keith and Brian (Eric), children Ana Paula(Brian) and Oliver (Brian).
Front Row: Elizabeth (Suzanne by special selection), Olivia(Kirk) and Charlotte (Kirk). Canines refused permission to use their names.

Sat...Dec 3

My exercise tolerance has decreased markedly in the past 5 weeks, since my first chemotherapy. Today my primary care doctor, Garry Kolb, in Morro Bay ordered an angio CT to rule out pulmonary emboli as the source of my shortness of breath. My friend, Jamie Kopper is here and took me to the scanning facility. Jamie is a pediatrician in Baltimore. We've known each other since high school and were especially close in college. I'm definitely having pain in the area of Lumbar 2 as well as in the left shoulder epaulet area and the left lower back. I'm using 3 or 4 doses of a narcotic on a daily basis.

Medical Situation 1977
As the partnership between Brendan and Stan dissolved in 1977, Brendan was also having problems with the hospital and it's administration. After Molly arrived in Glendive, Brendan asked us out for a dinner  where he offered to sell me his practice. At the time, my salary was guaranteed by the Rural Health Initiative (RHI) and I had little interest in a long-term investment in a medical practice. But, I recall a very pleasant evening sitting across the table from two full-blooded, beer-drinking Irishmen, Brendan and Molly.

Unable to sell his practice or to reach an accord with the hospital, Brendan left town and moved to Sydney, about 50 miles away. Many of his patients followed him, but I ended up with quite a few of Brendan's sick patients. It seemed that he directed the elderly and the sickest to me and told them that I had good medical skills. I believe that Brendan and I were able to look beyond the moment and see our mutual commitment to the profession.

With Brendan's departure, the RHI brought in three physicians in the Summer of 1977, a physician with one year of surgical residency, Fred Schneider, and a husband-wife team, the Johnsons from Yale, who practiced internal medicine and pediatrics.

The Public Health Service is a uniformed branch of the government. Originally founded to provide care for merchant seaman, its role had expanded during the Viet Nam years to allow some alternatives to traditional military service. Public Health Service physicians could be found on Indian Reservations and in rural areas throughout the United States.

So, within a few months, the RHI had gone from no physicians to 4 physicians. If I had been truly invested in creating a private practice in Glendive, I would have been upset to have the RHI increase my competition so markedly in such a short period of time.

On the other hand, the arrival of these physicians expanded our social options, provided more physicians for taking call in the emergency room, and increased our opportunities for more stimulating dinner parties. My salary was the same no matter how many physicians came to town. However, the accounts receivables were dependent upon productivity. But I wasn't greedy.

Getting Ready to Go
As bewildered as I was with the pregnancy in February 1978, Molly was more surprised and no doubt felt more vulnerable. Neither of us had made a conscious (or should I say vocal) decision about our long term plans. (I had a friend whose voice just said to me "Watch your feet!" His meaning would be that our behavior would say that we probably had made a decision being that we were together.)

In the Spring of 1978, we became a household in transition. I had every intention of leaving Glendive when it was convenient to do so--which meant that I would stay long enough to acquire the accounts receivables, that the baby would be born here, and that there was another job in place. I really liked the weather and low humidity of Montana, the visibility, the incredible depth of blue of the sky, the stars, and the people. I was hoping to find my way to Billings.

The initial shock of the pregnancy was gone and had been replaced by an optimism that things would get worked out. Brian was settling into a routine and attending the local daycare where he had a few playmates. Molly's youngest sister, Debbie, came from Maryland and joined our family for the next few years. We were actually having more fun and this was increasing with the size of Molly's waist. There was a lot of joy associated with that pregnancy and we were so much better prepared for Keith. The icing on the cake was a week trip to Flathead Lake and Lake Mary Ronan.

RHI versus RHI 
Believe it or not, in the sparsely populated area of Eastern Montana, there were two Rural Health Initiatives, the one in Glendive and another in the town of Colstrip, 160 miles away. The Glendive RHI was now quite flush with four active physicians. The town of Colstrip had two nurse practitioners but no permanent physician primary care services.

In May the Colstrip program made contact with me through the administrator. A few weeks later, the big boss administrator, Mr. A., came from the Denver field office to talk with me about helping out in Colstrip.  The meeting occurred at my house. It had been a very hot, over 100 degrees for the third day in a row, and our brick house retained heat too well. Stan came and we all sat out on the screened in porch until close to midnight and I recall the sensation of radiated heat from the wall behind me. Mr. A got ferociously drunk and gave me some useful information about what they could and couldn't pay for physician contract services.

Colstrip is exactly what it's name suggests, a region that was strip mined for coal for the Northern Pacific Railroad for many years and was closed down in 1958 when the railroad switched to Diesel. With the Arab oil embargo of the early 70s, there was much more interest in domestic energy sources. Of these, coal is the most abundant. In general, Western coal has a lower sulfur content and is less likely to create acid rain when burned in Eastern power plants. Colstrip was re-opened and the coal was shipped east in 100 car trains to fuel these Eastern power plants. At Colstrip, it was decided to build coal-fired generating equipment at the site of the fuel. It seemed that it would be cheaper to transport the electricity than to transport the coal.

Colstrip Power Plant

Colstrip had become an important part of the U.S. energy grid. It made sense for the Federal government to use the Public Health Service to supplement medical services in Colstrip which was 120 miles away from the nearest large medical center in Billings. This is actually the type of coordination that we should hope to see from the Feds.

I started to negotiate with the Colstrip RHI and already knew that there was a cap on the hourly rate and that there was an overall limit on physician expenditures. What was more flexible was the manner in which they calculated hours and they finally agreed to pay me for each hour that I spent on site, including time spent in the local motel waiting for the phone to ring.  It turned out to be a good arrangement for me. Although I was on call through Tuesday night, I always managed to get a some sleep.

I began to commute back and forth to Colstrip in the summer of 1978 and this continued for about six months which was the approximate length of the contract. This interrim job required only 2 days a week and permitted me to focus on finding a place in Billings and to begin to pack up our household--perfect for transition.

In September I interviewed for a job at a satellite clinic of St. Vincent Hospital in Billings. I'm not sure that there was any competition. I started working there two days a week in October and by the beginning of 1979 I had scaled back the work in Colstrip completely and was working full time in Billings.

I went to the administrator of the Glendive RHI in July 1978 and told him of my intent to leave after the birth of our child in September or early October. He was taken aback when he reviewed our contract and realized that the Accounts Receivables were now mine. Rather than worrying about collecting on these accounts, I was happy to agree on some reasonable percentage.

Armed with an infusion of cash and with a new job in Colstrip, we were waiting on Keith's arrival to make the move. Molly's ob doctor was Fred Schneider, the Public Health Service physician. When Molly went into labor, we stayed at home as long as possible by doing manual checks every 20 minutes. When we did go to the hospital, Keith was born in less than an hour.

And so, by the end of September 1978 our little family was ready to move on.  Quite a difference in the the pregnancies! Molly was able to establish breast-feeding relatively quickly. Her sister Debbie was around to provide support and help with the baby. Keith seemed to be very laid back. He slept well. He napped well. It was relaxing time. However, another Montana winter was around the corner and we needed to find a place in Billings. We would also be carrying mortgages on properties in West Virginia and Glendive.

The Northern Plains
The following link provides a  concise picture of the American Plains which encompass about 1.4 million square miles.  http://www.blueplanetbiomes.org/prairie.htm

For a general working "feeling" about northern tier states, the best two-book combination that I have found: Giants in the Earth by Ole Edvart Rolvaag and This House of Sky by Ivan Doig. Each is a masterpiece in its own right.

For a sense of the "vast," I think the movie Heartland starring Rip Torn  does a great job. As the movie closes, we see the little girl jumping rope. The shot must be using a telephoto lens because we begin to back away from her and backing away and backing away and seeing the empty space that surrounds her--a little girl who is tens of miles from another child, the now imaginable isolation. Its a wonderful movie on other levels as well. Most of us would say that we live in a society where arranged marriages are uncommon. I believe when we look back at the West, there were a lot of arrangements.

There were big differences between winter weather in Montana and West Virginia. The intense cold in Montana meant that the snow squeaked a bit under foot. It was much drier and harder to roll into snowballs or snowmen. At about 10 degrees F the mustache begins to catch moisture from exhalation and to freeze around the hairs. At about 0 degrees F, there is a tingling associate with some freezing of moisture inside the nose around the hair.

The wind chill factor was very obvious. At zero degrees in midday without a breeze, one can comfortably ski cross-country in a flannel shirt and ski cap. When the wind kicks up to 15 or 20 miles an hour, things begin to get uncomfortable. One winter in Billings I had problems with the International Scout's heater and I drove without one for several months. The most significant change was an overall sapping of energy with less energy in the evening.

Billings as a Medical Community
I love the feeling of the towns that border the Eastern edge of the Rockies, whether it is Calgary with fast running water within the town limits, or Denver with its increasingly cosmopolitan feel. I have a special love for Billings as a result of the seven years that I spent in Montana.

In Glendive, there was a stretch of time of more than 12 weeks where we were confined to town by call schedules or Ob deliveries or weather. Finally, there was a clear week-end. We went to Billings for some recreation, checked in at a hotel that had a pool for Brian, ate in a few restaurants and actually decompressed. It was dark as we drove back on Sunday evening. We passed the little towns along the way, including Miles City that had twice the population of Glendive. The area of lights was so small compared to the immense prairie. I had just lived for 12 weeks with hardly a thought or concern that exceeded the boundaries of the town. I had been "locked in." I realized that if I were going to be locked in, Glendive would not be the place that I would choose.

My first exposure to Billings was to its medical community and it was first rate. Although the population of the city is about 100,000, its medical footprint is much bigger because it is a regional medical hub and draws patients from the entire eastern part of Montana, parts of North Dakota and South Dakota, and a fair portion of Northern Wyoming.

As a family physician, an essential task is the establishment of a referral network. This is something that happens over time and began the first day I had begun practice in Glendive. Even living 250 miles away, I was in contact with physicians in Billings on a daily basis. By the time I left Glendive, my referral patterns were pretty much in place.

When I parked in the Doctors' Parking Lots at the two Billings hospitals, I saw an abundance of personalized license plates, like BRAIN, HEART, etc. Not to be outdone, I tried for Quack but it had already been taken. I had to be satisfied with MDKWAK. It let folks know that I had arrived.

Here is a picture of Billings. The most prominent geological feature is the Rimrock. The city sits below. The Airport is above the rims.

Billings, Montana. From Matthew Muller. matthewmuller.com

The Beartooth mountains are a one hour drive from town. One of the more magnificent sights that I saw on a daily basis was the Beartooths framed in the windows of the 4th floor of St Vincent's Hospital.

Huntley Project and the Worden Clinic

If you drive east from Billings on I94 you will pass Huntley, Worden and Ballantine, and Pompeys Pillar over the course of 30 miles. These are the towns of the Huntley Project. The "Project" was the building of an irrigation system in 1906. I was told by locals that one could homestead in exchange for "sweat equity" in the construction of the irrigation canals and ditches on the South side of the Yellowstone River.

At the time that I arrived there in 1978, the irrigation project had been operating for about 70 years. Nevertheless, there were quite a few fits and starts during the first 20 years of operation. The following document provides quite of bit of detail about the engineering aspects of the the system.

http://www.usbr.gov/projects//ImageServer?imgName=Doc_1305043992002.pdf

A lottery was held for available homesteads that didn't go well initially as described below

The District Land Office received 5,491 applications from prospective homesteaders before the closing date of June 25th. Secretary of the Interior James R. Garfield presided over a drawing to determine the order of preference in land selection. It turned out that many of the registrants were from Billings and applied only to see what number they would draw. These
lottery fanatics had no intention of settling on the project. Many prospective settlers traveled great distances to register, only to find themselves far down the list. Most returned home thinking all the lands would be filed upon and they would have no chance of getting a farm. Of the first 1,000 names drawn only 76 completed filing.

On August 23, the registration list was exhausted and the lands were opened for unrestricted entry. As a result, 
settlement on the Huntley Project started slowly. Only 4,100 acres of land were cultivated in 1908. By 1910 the
number of occupied farm units increased to 352 containing 20,905 acres, but only 12,000 acres were cultivated.


In 1978 were several people alive in their 80s and 90s who had been original homesteaders. Most lived with the next generation of farmers, but some such as Gus, lived alone with his wife.

Gus
He never called when he was sick. Generally, his son or daughter-in-law would get in touch at inconvenient times. He had survived three heart attacks and suffered from congestive heart failure. He came to the office once, but refused to come again.


I guess I visited him every month or two. He would generally be sitting in an easy chair. His eighty year-old second wife would be scurrying around in the kitchen while he barked at her. She was deaf and ignored it all.


His heart failure had increased his girth and he always had his trousers unbuttoned. He complained about the cost of everything and I could never depend upon him to purchase his prescribed medications.


He was one of the early homesteaders and he was certainly a land millionaire. His son appeared to live a very comfortable life on a part of the land.


Gus described the construction of his first house: "I harnessed up the horse and we plowed furrows. Then we harvested the sod and built the walls of the house. When the walls dried, we whitewashed them. That's what we lived in for the first three years."


"You know, Doc, the trouble today is that people is living too high on the hog."

 Sod home of John and Marget Bakken, Milton, N.D., circa 1895
courtesy of memory.loc.gov 

The clinic for the Huntley Project was located in the town of Worden at the end the main street which extended a block or two. It was a one story brick building with several exam/treatment rooms, an x-ray machine, a small lab, spacious waiting room and front office space. The parking lot was gravel. The previous physician had moved on. He was kind enough to come visit before I started and expressed some regrets at leaving. The Sears foundation had constructed the clinic in the 1960s in order to assist the town in obtaining and keeping a physician. The following article is an interesting summary of societal concerns about rural medical practice in the United States from 1921 until 1989. It's hard to imagine that we have lived in a wealthy country that can't seem to come to provide a general medical safety net without all the political invective.

http://www.shepscenter.unc.edu/rural/pubs/report/WP5.pdf

My mother could never understand why I wasn't more interested in a medical practice in the D.C. suburbs. I've preferred farmers, ranchers, and fishermen--they are more grounded. Farmers and ranchers have taken care of sick animals. They know that bad things can happen that are no one's fault--just misfortune. I wouldn't have understood the meaning of the word in 1978, but the sense of entitlement is much more likely to be found the closer one gets to large cities.

We Haven't Started to Live
I was working an emergency room shift at North Arundel hospital in the fall of 1970. A nurse came running to tell me that someone had collapsed in the parking lot. I ran out and there was a youngish looking man lying on his back. First responders were already there and had begun CPR. We managed to get the man onto a gurney while continuing resuscitation attempts and brought him into the emergency room where we worked on him for the next 90 minutes or so before calling off our attempts as futile. 


His wife arrived shortly thereafter and it was my job to tell her that her husband was dead. She was incredulous and looked at me. "How can he be dead? We haven't even started to live." She expressed some outrage that the attempts to resuscitate had been stopped before she had given permission to do so. I was concerned enough about her attitude to call the administrator's office and advise them of the situation.

In Montana patients seemed more respectful. I don't think there are any patients tougher than cowboys whom I'e seen manage a broken bone over the week-end rather than disturb the doctor.

Marie
She was tall, thin, and strong with regal posture--the maiden aunt of her clan--a retired school teacher who was fiercely independent. She lived alone and drove her automobile all over town.


She was in her 80s and had spinal stenosis that limited her ability to walk any distance without pain. She also had intermittent episodes of supraventricular tachycardia that required brief observation in a monitoring bed once or twice a year.


She basically needed me for her acute episodes. Her routine office visits were just medication checks and an opportunity to visit.


Her acute episodes were generally resolved in a few hours with an additional dose or two medications. She could tell when the episode had resolved and she would remove her telemetry wiring, don her normal clothes that generally included a long skirt, a blouse and a neck high sweater. She would then sit in a chair and wait for a physician to appear to discharge her. Some of the nurses had a problem with her self-sufficiency. I thought her spunkiness was a good thing.


Her last illness was probably a stroke. She called the office and said that she had fallen and could not move her right arm. I met the ambulance at her home and talked to her as we loaded her for transport. However, by the time she arrived at the hospital she was no longer conscious and did not respond to anything but deep pain.


Its been 30 years now, but my recollection is that she remained in this state for at least a week. I had her seen by the usual specialists. I saw her daily on my rounds and held out very little hope that she would recover. I thought that the persona of Marie had already left. However, two days before she died while I was doing a brief exam during rounds, she suddenly opened her eyes and looked directly at me and said, "Thank you for everything." At which point she closed her eyes and was again non-arousable. When she spoke I was 100% convinced that she was totally present. She died within 48 hours.


My Alcohol Consumption
For the first two years of practice in Billings, I drank alcohol on a daily basis. My work day began with a five mile drive to the hospital to make rounds, then a twenty-five mile drive to the clinic in Worden. When the last patient was seen, there was another twenty-five mile drive back to the hospital for evening rounds, and finally the five mile drive home.

I began to feel that my day actually began when I walked through the front door of my house and headed for the refrigerator for the first beer of the day. Generally, I would have another beer with supper and at least one or two more in the course of the evening.

I began to worry about the fact that I didn't seem able to limit my use to two drinks a day. No matter my intention prior to the first drink, any resolve was gone by the second drink. Occasionally I would drink to the point that I had a hangover the next day. I found myself avoiding food in the morning and eating a breakfast meal at about noon. I was at a friend's house with the boys on the Saturday of the Army Navy game. I found myself feeling "buzzed" early in the afternoon. Then I saw Keith and Brian, aged 2 and 5 playing with the other children and I felt a sense of shame and disgust that I was becoming intoxicated while responsible for them. At that moment I stopped drinking on a daily basis.

From 1980 until 1982 I seldom drank and when I did, I was able to limit it to a single drink. Most of the time, I just turned it down.

In 1982 I was visiting the East Coast and my siblings and I were at a pizza restaurant. Everyone was having a beer, so I ordered one as well. When the waitress asked about beer refills, everyone ordered the second beer. When the waitress came back and asked about a third, everyone turned her down. However, I wanted the third beer very badly. I didn't order it but I became aware that my desire for alcohol increased with the amount of alcohol that I had already consumed--that it was not possible for me to feel satisfied with small amounts of alcohol. That evening I quit alcohol for the next 23 years.

In 2006 I started drinking small amounts of wine on social occasions. I find that my limit is about 4 oz of wine or a single beer. I get a great deal of enjoyment from them.

Dave Wilms
Dave and Jan Wilms were the publishers of the local newspaper in Huntley Project. They were in their 30's and had requisite energy to publish a local paper on a shoestring. Dave covered all of the local sports and Jan did most of the news stories and interviews. I first met them when she came to interview me as I was starting practice at the Worden Clinic. 


Dave and Jan loved movies. A few times a year we would rent a VHS player and a handful of movies and do an all-night movie fest. 


A few years after I left town, Dave developed renal cancer and had metastases before a diagnosis was made. He developed one complication after another, one problem after another. On the day before his death in 1989 he was visiting his primary care doctor. Dave had so many problems that the Doctor didn't know where to start but the doctor wanted to make Dave as comfortable as possible. So the Doctor asks, "Dave, what is it that bothers you the most?"


Dave says, "The fact that George Bush is president of the United States."