Friday, August 1, 2008

Tackling tuberculosis

Yesterday morning, a gap appeared in my schedule for the first time in 14 months; tuberculosis rounds skipped a weekly meeting as we begin winding down our strenuous efforts to battle a tuberculosis outbreak in Yellowknife’s homeless population. Finding patients, dealing with substance abuse and adjusting regimens for toxicity often seemed straightforward in comparison to the task we were given by local administrators: prevent the next outbreak.

For nearly 5 years, a small collection of hospital and Public Health staff have met twice a month to review all TB cases in the Northwest Territories. Although I chair the group, I began with very little knowledge of the disease and its treatment. I was willing, however, to serve as a figurehead (being the only physician), to ensure a connection between Public Health, community nurses and hospital staff as patients moved between the hospital and the community during their long treatment courses.

In the process, a wealth of knowledge gradually rubbed off on me as the lab staff, community nurses, infection control nurse and TB program coordinator all contributed their perspectives to patients’ care. Since all of the TB players were around the table, we also began adjusting our standing orders, hospital policies and communication pathways to better suit the needs that we identified in the course of patient care. We had no terms of reference, no budget and no official status in the hospital; life was good under the radar.

Then came the outbreak - and with it some finger-pointing between health boards, since the index case was missed for at least 6 months. Contact tracing identified hundreds of individuals potentially exposed to tuberculosis, many of whom had no phone number or fixed address. For years, I had been trying to keep TB on the agenda of physicians and administrators, pointing out the high rates in the NWT of both latent and active disease. Suddenly, everyone was interested in tuberculosis, and our little rounds group had to grow up, with terms of reference, a reporting structure, and minutes of our “systems rounds” where we left no stone unturned in examining the barriers to TB diagnosis and treatment.

An astute nurse pointed out that the first 6 cases had all slept in the same room at the local shelter, for a minimum of 5 nights out of the 2 weeks prior to the index case being diagnosed. In response, the TB program coordinator asked for an inspection of the shelter’s ventilation, and we worked closely with shelter staff to choose a new air filtration system – then lobbied the Department of Health to pay for it. The shelter staff were trained to be “cough monitors” – common in developing countries but not often used in Canadian TB control programs – (unless you happen to live in Yellowknife).

The infection control nurse pointed out that our isolation strategy would quickly overload our hospital’s resources, if several patients were simultaneously on treatment or under investigation. The Medical Health Officer (now an enthusiastic rounds participant) researched and developed a new isolation policy. “Coming soon to a hospital near you… a portable sputum induction isolation booth!” she announced, as we oohed and aahed over the glossy photos – and again, lobbied for the necessary funds to be released.

And what about the jail? Our TB patients often spent time in corrections, so the relevant nurses called in to meetings to confirm continuity in treatment regimens. We streamlined communications, and drafted a protocol for treatment of latent TB within the correctional system so that no opportunity (especially a 4-month prison sentence) will be missed in the prevention of active disease.

One of the emergency room physicians offered his department’s help in the investigation of contacts. “I know all these people you’re looking for,” he told a Public Health nurse. “I stitch up their cuts on Saturday nights. Just tell me what you need, and I’ll start getting sputum samples.” Designing an interdepartmental flagging system was complicated, but we tiptoed through the confidentiality and information transfer issues until a practical, ethical solution was found. In retrospect, this initiative alone would have prevented the Yellowknife outbreak, since the index patient sought care multiple times in the ER and various clinics; but there had been no way to flag his need for sputum samples.

To create a body of physicians comfortable with treating TB, I offered a 6-week course on Saturdays to interested nurses and doctors. Surrounded by journal articles, case summaries, and the Canadian TB Standards one Friday evening, I wondered how I found myself in this position. I think the call of the rural physician will always be, “Do what needs to be done.” Sometimes that means writing letters about ventilation systems, or visiting the nurses at the jail, or simply educating myself to do the task at hand. There is expertise and help, if we can recognize it in a shy lab technician or a shelter worker; but these unsung heroes often need a physician’s support to make their voices heard, and to see their work come to fruition.

Monday, July 28, 2008

A visit to my favourite little northern town

This morning, I will board a plane for Fort Simpson, a community of about 1200 people that I have visited every 2 months for the last 6years. From clinic, I drive 7 minutes to the airport, arriving at 9:55 for my 10:30 flight. (Although we have a fancy security system for flights going south to Edmonton, it’s not used for flights within the north.) I arrive in the 1-room Fort Simpson airport 45 minutes later, having been fed and watered 4 times by the flight attendant; she had only 12 passengers to look after today, and apparently a large surplus of food to dispense.

Upon landing, I retrieve the heavy metal suitcase that houses a pacemaker programmer, musing that every upgrade makes these machines heavier -- the opposite of most computerized technology. I suppose they aren’t designed for carting around the Arctic. A familiar voice begins greeting everyone in the airport; it’s Dale, the driver with a cackly laugh and a filthy truck who the bed & breakfast sends to pick me up when the hosts are busy. Dale swings my fragile luggage into the back of his pickup truck and we head down the highway, chatting about the weather, his wife’s health, and recent bear sightings in the area.

The health centre is run by a team of nurses, who provide first-line care and decide who needs to see the doctor. One nurse handles prenatal care and well-woman clinic; another runs the walk-in sick clinic, another the chronic disease program, and so on. Every few years they rotate programs to maintain skills, and each morning at sign-out the nurse-on-call presents the previous night’s cases to her nursing and physician colleagues. At morning report, new nurses receive a crash course in northern medicine: “Fred came in coughing? He needs a sputum for TB; he’s on the high-risk list. And if Joey has a boxer’s fracture, chances are that Sonny has a broken jaw; they were arguing outside the bar last night. We’ll ask Home Care to stop by his place.”

The chronic disease nurse runs the internal medicine travel clinic, and it is indeed a tight ship. Every diabetic has a recent glycosylated hemoglobin on the chart, and no one seems to forget their medications -- unlike my clinic in Yellowknife. If I ask for a blood test, an ECG and a chest x-ray, my nurse performs all of the tests herself and leaves the film on the viewbox for me to review. Any social background I request on a patient is answered by colourful stories of community life -- generally more detailed than I would like to know, but interesting nonetheless.

Monday afternoon I see patients from Wrigley; Tuesday morning includes Fort Liard and Jean Marie River, and the occasional consult patient is flown in from Nahanni Butte. These tiny communities actually view Fort Simpson as a regional centre, and some are served only by an on-site lay health worker, with fly-in nurse visits every month or so.

One of the more unusual clinics greeted me the first time I came to Fort Simpson; I commented on the number of dogs in the waiting area, and the nurse told me it was Lois’ clinic day. “Is she a vet?” I asked. “Oh no, she’s the long-term care nurse but she takes care of doggy shots and boo-boos on her days off. There’s no vet in town, and we figured she could use the clinic space once every couple of weeks.” Who was I to argue?

Lois took a turn at managing the internal medicine clinic a few years ago, and I commented that I was concerned about the social isolation of a patient I followed for congestive heart failure. “He’s so young, Lois, and I don’t think he has any personal connections to keep him going,” I commented as I represcribed his medications. She nodded thoughtfully, and a couple of months later she told me he was doing much better. “Did he meet someone?” I asked hopefully. Lois leaned forward, her eyes twinkling. “I gave him a kitten,” she told me earnestly. “He carries her everywhere, even to the grocery store. He just adores her, and she’s had all of her shots.” The thought of my corpulent patient lavishing affection on a tiny kitten made me laugh outright; but I couldn’t ask for more holistic care.

A few years ago, Fort Simpson was blessed with a remarkable physician who served the community half-time, spending the rest of his year at his family’s ranch on Salt Spring Island. Shane invested heavily in nurse education, and the bulletin boards in examining rooms are covered with the protocols he wrote up for the diagnosis and treatment of common conditions. Strep throat scoring systems, first-line therapy for UTI’s (including who needs a culture), antibiotic protocols for cellulitis, and prenatal visit guidelines jostle for space among various notices from the Yellowknife specialist clinics.

Among the protocols is a tiny scrap of paper titled “the internist”, with my cell phone number underneath. Apparently Fort Simpson doesn’t consult the call schedule; and in truth, I would rather be the one to find out if a familiar patient runs into problems. The doctor’s office even has a photo of “the internist” with her jolly redheaded baby, enjoying a holiday in the south of France. Jeannine, the nurse who runs the bed & breakfast, always stops by to chat or offer me a drink after clinic. And if I still lacked a sense of social belonging, in my favorite little northern town, I’m sure Lois would find me a kitten.

Thursday, July 24, 2008

To soar, or simply to survive

This weekend, after 6 years in Yellowknife, I finally joined local aviation enthusiasts for the city’s annual air show.

I went for my son’s benefit, but I will never miss the show again. My 2-year-old ran wildly in circles among the planes near the hangar, trying out one cockpit after another and gleefully crowing to me from the windows: “Mummy! I’m in the plane! I’m in the plane!”

Since my husband has more energy than I do these days, he did most of the chasing while I watched the aerial performances — mesmerized by the beauty of a single plane in its huge playground of sky, rolling and twisting its way through figure-eights simply for the joy of flying.

The north has a love affair with flying, and with the pilots that opened this land to development and discovery over the last century. The local heroes (except for prospectors, hunters, and community nurses) are often the pilots who could fly in the most desperate of circumstances, fix their own planes if needed, and wisely recognize their own limitations in extreme weather conditions.

Preparedness is essential, and even a business traveler on Air Tindi will be refused boarding in February if the flight crew don’t think his parka is adequate. Some flights to my travel clinics have only a pilot and co-pilot, who calmly explains where to find the emergency transmitter and survival gear in the event of an unforeseen landing. When a flight attendant is present, passengers are treated like royalty; no first class is necessary, since everyone is fed and generally spoiled on even a 45-minute, mid-morning flight.

Northern pilots and medical staff are inextricably linked, since we frequently collaborate to bring patients from far-flung communities and camps to a point of medical care.

More difficult, though, is the relation of a physician to a pilot as a patient. How can I hope to obtain an accurate blood pressure in clinic, when the pilot knows he will be grounded until I certify him as healthy and ready to fly?

A young man who spent his entire life longing to fly, and training as a commercial pilot, was recently diagnosed with diabetes. My role, at his second clinic visit, was to confirm his worst fears — he would need insulin to control his blood glucose, and would never fly again.

Another pilot, who lives with his wife and children on a remote homestead surrounded by wilderness, was grounded when an ECG showed inferior Q waves. Although he was only grounded for a week (until I repeated the ECG with more careful lead placement and performed a stress test), he faced the possibility of giving up his home, his lifestyle and his profession since even a trip to town for groceries depended on his pilot license.

My greatest fear for a pilot is that he or she will not seek medical help in a timely manner, due to fear of being grounded.

When I was still quite new to Yellowknife, I was called to a code in the emergency room for the husband of our finest critical care nurse. He had been mentioning some arm pain for a week, but wouldn’t seek medical attention. He shoveled the driveway one morning, drove to the airport, and was stopped for driving erratically — fortunately before he strapped on his pilot gear and put other lives in danger.

By the time he arrived in Emergency, the pilot was asystolic and could not be resuscitated.

My colleague was now a young widow with children, all because of a pilot’s fear of losing his license.

His career had included flights to Antarctica and he was head pilot for the toughest employer in the north. His employer’s father, 82-years-old, was recovering in hospital from an uncomplicated myocardial infarction on the day that pilot was brought in. During rounds, I spoke with the weathered airline boss – he flies DC-3’s and looks as tough and indestructible as those planes.

“Yeah, they brought in my head pilot today,” he commented, looking past his elderly father. “Forty-three years old. Makes you wonder.”

The memorial service was held in the huge hangar at the airport, and the deceased pilot was honoured with a fly-by of his own plane.

I was still new to the aviation culture, and much of what was said in the service was beyond my comprehension.

But I realized that aviation seems to mirror the landscape of the north in many ways — with its power and fragility, its complexity and grace, its very human desire to soar — or simply to survive.

And perhaps, to that extent, it’s a lot like medicine too.

Monday, July 21, 2008

The intersection of faith, family and survival

Bill’s daughter Mary is worried about him again. He is elderly and she fears he is over-committed in the community, considering his multiple medical problems.

She hasn’t approached me this time with her concerns, but it seems I cannot escape them, it being a small community. On Sunday at lunch, I am sitting at the corner table of the “Chinese-Western Diner,” feasting with my family on wonton soup, grilled cheese with ketchup, and buttermilk pancakes. A mutual friend approaches and asks me, as Bill’s physician, whether I think he should slow down, and in particular, cancel a bible study group that meets Fridays at 7 a.m. at a tiny local church.

I weigh my words carefully, wanting to protect the dignity and confidentiality of all involved — but particularly my friend, mentor and patient. “Well, I think Bill is in the best position to decide how he wishes to spend his energies, and I’m sure he’ll consider (well, consider, then happily ignore, judging from prior experience) his family’s concerns.”

“Great,” she responds with a smile; “See you Friday at seven.”

I turn back to my husband Paul, who stifles a chuckle. “It must be hard for Mary to sleep in when Bill is shuffling around the house at 6 a.m. on Fridays,” is his only comment.

Paul loves Friday mornings as much as I do; after bible study at church, I drive Bill back to our house, where Paul reads to him for an hour or so over tea. Bill still subscribes to his favorite magazines, despite losing his vision to macular degeneration, and Paul enjoys the excuse to read archaeology, history and international news with a good friend.

During residency, I was frequently warned not to serve as a friend’s physician, but my perspective shifted after moving north. It has been said that in a small community, physicians who won’t treat their friends have either no friends or no patients.

Yellowknife is large enough to balance these approaches, depending on the situation; and Bill has always preferred to be under the care of someone he knows and trusts as a friend. At times I have distanced myself from his care, insisting he also have a family physician and stepping out while a colleague on call prepared for a transvenous pacemaker insertion.

The hardest area has been discussion of code status. After a particularly difficult year — punctuated by repeated hospitalizations and a few medevacs — we addressed the topic in the comfort of my clinic.

I felt foolish outlining the question to a minister who traveled 3000 kilometers per year by dogsled in “the early days,” witnessing Inuit families torn apart by tuberculosis treatment and conducting funerals for infants who died on the trail during Arctic migrations. Bill understands human fragility far better than I do, and has had 50 years in the Arctic to reflect on the intersection of faith, family and survival.

He nodded slowly, and smiled.

“Yes, I understand what you are asking. I trust you and your colleagues to make the right decision, and I hope that the physicians looking after me would contact you and speak with my family as well.”

In his own wise way, he sidestepped the easy questions — tube or no tube? CPR or not? — and yet provided exactly what I needed to know.

Clinical situations change, but the guiding principles of his life – which he knows I share – will ensure that he lives and dies with grace, dignity, and hope. The best I can do for his code status is to advise: “Be sensible, be compassionate, and please call me.”

Monday, July 14, 2008

The outpatient inmate

I received a fax this week from a corrections nurse in Saskatchewan, asking for details of a patient’s pacemaker so that he could receive appropriate follow-up at the pacemaker clinic closest to what I assume is a federal prison. I sighed – Bob was in trouble again – but at least he wouldn’t be selling drugs to teenagers in Yellowknife for the foreseeable future.

I remember distinctly the first time I met Bob; the GP on call consulted me from the emergency room for atrial fibrillation. A pleasant guard stood to the side while I asked Bob a few questions. “They think I’m faking it,” he told me defensively. “But my chest doesn’t feel right, especially when I lie down.” He had no medical history except for a pacemaker insertion a few months prior and took no medications. His distended neck veins and a soft precordial rub told me I wasn’t dealing with run-of-the-mill atrial fibrillation, and the chest x-ray showed almost a circular cardiac silhouette. We had no echo services, but fortunately the cardiologist in Edmonton agreed to see him if we sent him down by medevac for possible pericardiocentesis.

“I guess that means I’ll be going, too,” the guard commented politely. “How long do you think he’ll be in Edmonton?” I couldn’t tell him many details, but we arranged the flight; and I must admit I felt vindicated to learn that the skeptical cardiologist had removed several hundred ccs of fluid from the pericardium upon the patient’s arrival in Edmonton.

For months I didn’t see Bob again; he had been released from prison and tended not to come to appointments on his own accord. I did, however, see the guard again at a local coffee shop a few weeks later. We spoke briefly, and when he heard I was looking for a reliable old car, he directed me to a 12-year-old Subaru station wagon he had been thinking of buying. An amateur mechanic, he had considered its many selling points: “You know, Amy, I went hunting with one of my buddies who had a Subaru wagon. We got a huge moose, and the whole carcass fit in the back of that car! Great trunk capacity, those Subaru wagons.”

I was duly impressed and bought the car the next week. Although I haven’t used it for moose hunting, it was the designated transport vehicle for a double bass prior to a performance of Handel’s Messiah last Christmas. None of the choristers’ SUVs could squeeze in the bass and it was too cold (minus 43 without counting wind chill) to cart it around in a pickup truck.

When my patient surfaced again, he was back in corrections for drug dealing and some break-and-entry charges. (It’s hard not to notice when your patients keep showing up in the local newspaper.) He was clearly relieved to discuss his medications with me, specifically whether he needed to continue sotalol now that he had been free of palpitations for a few months. He also wanted to review options to treat his hepatitis C; I told him I would only consider initiating treatment if he was sober and out of jail for several months, or if he had at least a 1-year prison sentence to allow a full treatment course in corrections. He thanked me politely for my opinion “and for saving my life back in September.” I wondered privately what he intended to do with the life remaining to him, but kept my comments to myself.

Only once, in frustration during a clinic visit, did I tell Bob that it was difficult to care for someone who only came to appointments when incarcerated. “I’m tired of seeing your name in the papers,” I commented, and was surprised that he said nothing to defend himself. As a rural physician, it is very hard to ignore the impact that someone has on my small community. How many of my friends’ children have been tempted towards a path of destruction by my patient’s efforts, I will never know – nor would I dream of trying to find out. I can only hope to provide some degree of respect, hope and patience towards a man whom I have only ever encountered as a patient.

And that Subaru? Six years later, it’s still going strong. It needed a new transmission a few years ago, but the guard turned up again just in time to find me a great deal from a wrecking yard out of town. I guess I have my debts to Bob as well.

-- Dr. Amy Hendricks

Thursday, July 10, 2008

Rural medicine lessons for residents

Last week marked a new rotation in the academic medicine schedule, and 2 residents landed in Yellowknife to begin their rural internal medicine rotations. One of them joined me yesterday for clinic. By the end of the morning, he asked if he could ask me a “program” question. “I’m not sure I understand how you utilize subspecialists up here in Yellowknife,” he commented. “Do you call them for advice, or send patients down for consultation?”

I remembered my first few months in rural practice, which included several desperate phone calls back to McGill (where I had trained) for advice. During those days, I was intimidated by the clinic setting and spent hours each day checking notes and online education resources to ensure I was managing patients appropriately. Six years later, life has changed considerably.

“Well,” I replied, “I send patients down when they need a procedure – an MRI, cardiac catheterization, perhaps a MIBI scan. I’m not as strong at rheumatology or outpatient neurology these days, since we have excellent locums who come every 3 months and see patients from all over the north here in Yellowknife. I don’t usually send patients out for an opinion on a cardiology or diabetes patient, since we’re able to offer good service here in the north.”

He thought back over the morning. We had followed up a patient post-ablation for WPW, discussed pharmacologic and other options for SVT with a teenager and her mother, and reprogrammed the pacemaker of a patient from Ulukhaktok, a tiny hamlet on an island in the Arctic Ocean. I had spoken to an Edmonton specialist regarding changes to an outpatient tuberculosis regimen due to drug intolerance, and I was trying to book a pregnant type II diabetic within the next couple of days, to start her on insulin. The tuberculosis and pacemaker cases presented us with some good teaching opportunities, and we also discussed the benefits of continuous glucose monitoring systems in selected diabetic patients.

“I guess I didn’t expect all of this to happen in one place,” commented my resident. “I don’t think that’s what internists do in downtown Calgary, is it?” Having never worked in Calgary, I had no details to give him regarding the outpatient life of internists more familiar to him. “I’m sure that each of them has a practice profile suiting their expertise and meeting a need in their community,” was the best I could do.

I never chose tuberculosis, or pacemakers, or insulin pumps, as part of my job description; in a small community, a specialist’s role develops around local needs and to complement local expertise. Most gastroenterology questions are punted from my desk to a couple of colleagues down the hall, and they reciprocate with nephrology referrals since I work most closely with our dialysis and renal insufficiency programs.

In the afternoon, the resident joined me for stress testing, and we started out with a patient from the small community of Fort Smith. A young man with previous coronary bypass surgery and chronic atrial fibrillation, he clearly needed consistent care to prevent future cardiac events. I listed him for annual stress tests – not because they are necessarily indicated, but because they will guarantee he sees an internist at least annually to review his lipids, diabetes management, ventricular rate control, and cardiac status. “Fort Smith just lost its only permanent physician,” I explained to the resident, “so I can ask the nurses to watch his heart rate, lipids and so on – but I can’t guarantee continuity of physician coverage unless he’s kept in our system.”

The next patient, from Yellowknife, had been unable to find a family physician for months. He had a reassuring stress test but multiple cardiac risk factors. “Our nurse practitioner will follow up his lipids and smoking cessation,” I told the resident; “If anyone can help him stop smoking, it will be an ex-smoker who has plenty of time for phone and clinic follow-up.”

Sometimes it seems that every community in the Northwest Territories has a different model of care, which changes as local medical resources ebb and flow. My resident will soon board another plane for a 1-physician community, where the visiting internist is treated to lunch in exchange for a spontaneous lecture to the local nursing staff on the topic of their choice. He will see patients from the bush and patients from the town, and offer advice and encouragement to the nurses who give most of the medical care to the region’s scattered population.

Perhaps one day my resident (or one of his colleagues) will give himself to a small community, becoming the internist for an otherwise unserved population, learning and growing with local needs and programs. Granted, it is a model he has not seen before; but it is the only life I have known since I was foolhardy enough to accept a 1-way ticket here from Montreal. I do miss the opera, but otherwise I wouldn’t change a thing.

-- Dr. Amy Hendricks

Thursday, July 3, 2008

Words are not wasted when there is soup to deliver

Spring came reluctantly to Yellowknife this year, but finally the ice bridge over the Mackenzie River gave way to a ferry crossing, just in time for my new grand piano to travel by road from Kelowna.

I arrived home from work to find my friend and trusted piano dealer in my living room, after he had spent 3 days on the road with the piano. The next challenge was to wrestle the piano into our inaccessible living room.

Then the cell phone rang. I wasn’t on call, but I smiled when I heard a familiar voice: “Hello, it’s Anna from Home Care. I’m so sorry to bother you, but I can’t reach the physicians who have been following one of our palliative patients …”

The family physician was in an outlying community, and the locum covering his practice first tried to send the patient to the ER and then could not be reached by phone. The palliative care “call group” in Yellowknife consists of myself, anytime, as long as I can be reached, precisely because of situations like these.

The patient, a young father of 3, was dying at home of a malignancy. He had just been started on some morphine for respiratory distress, but Anna felt he would benefit from a benzodiazepine as well. I couldn’t give her a phone order for a patient I’d never seen, but we arranged for a home visit the next day — my day off, but I would welcome another commitment around the time that my piano would be dangling from a crane in the front yard.

Next came the delicate task of soliciting a consult. I cannot advertise myself as a palliative care specialist, but most family physicians accept my involvement through Home Care during their own absences, or in the event that a homebound patient requires internal medicine services. Yellowknife’s Home Care nurses are the local experts in symptom management, and they can usually wrangle a consult when needed. In this case, the family physician was happy to oblige.

Arriving at the little house the next day, I found the door open and walked in to find Karen, another nurse, at the kitchen table. The patient’s young wife, wearing pyjamas and a bandana, had more dignity and grace about her than many a suit-clad business type.

She handed me a plate of waffles, pointed to the syrup, and continued her discussion of which medications were really needed at this point.

A middle-aged, cheerful fellow walked in just after me, carrying a large pot. “Beef barley,” he told the patient’s wife. “There’s space in the fridge,” she replied; he deposited the soup and left with a nod and a kind smile.

Between mouthfuls of waffles, I made some suggestions for medications, and phoned the pharmacist. I spoke with the patient, who awoke from a snooze on the couch to smile warmly at his wife and submit to a brief examination.

I didn’t need to know much; he had no pain, was scared but trusting, wanted to stay home until he died, and felt better with tiny doses of morphine and the occasional sleeping pill. I would come back on the weekend for another visit.

Before the next visit, I was called again — this time to declare the patient deceased and fill out the relevant paperwork.

The house was sad but peaceful, and his wife still wore her dignity and tenderness — perfectly paired with overalls and a t-shirt. A neighbour sat in the front yard with a phone, working her way through a list of names, and the coffee pot was rumbling again.

As I left, I reflected on this little town, where isolation breeds a kind of practical connection between neighbours and among health care workers. No one lives more than 15 minutes away, and words are not wasted when there is soup to deliver or a prescription to pick up. Many of my patients list neighbours as their “next of kin” on hospital records; and as for the Home Care nurses — well, they know where I live, and they’ll deliver an internist to your kitchen table if they think she can be of assistance.