Lit up

I stayed in Seattle Monday night. The city is lit up with excitement about the Seattle Seahawks. I stayed at the MarQueen hotel, which is lovely and old, and went to the coffee shop in the morning. I asked about the lights in the picture: the block next door was lit up blue and green.

“It’s a park,” said the counter woman.

“Is it always lit up?” I asked.

“Oh, it’s blue and green for the Seahawks!”

It was a lovely stay.

The Tiny Soldier Part 4 (Flash Fiction Chain #5)

Here is my addition to trablog’s flash fiction chain 5, thanks!

Character List :

Rick – a not so ordinary ten year old

Jenna – a social service employee

Mrs. Montgomery (ma) – the foster mom

Jake – Mrs. Montgomery’s only son

Sun – The monkey

Recommendation:

Read the first three parts before venturing this part.

Part 1 : Written by Abirami

Part 2 : Written by Sona

Part 3 : Written by hiddenstarsfiction

Part 4

Rick settled on the ground and Sun stood on the wires above him.

“I think better in motion, O Best Beloved.” said Sun. “You desire to know how I became the monkey? The first monkey?”

“Oh, yes,” said Rick. Books were his hiding place and passion and escape as a foster child, but to have someone TELL him a story….  He tried not to think about it or hope. They would probably be interrupted.

Sun looked up at her namesake, starting to warm the dry courtyard. “A’Tuin, the giant turtle who swims, you know of him?”

Rick nodded. “Discworld.” he said.

Sun frowned. “Oh. This isn’t Discworld, is it.” Rick shook his head. “You know that there are many universes? And many stories. Which is your origin story?”

“This is earth,” said Rick reluctantly. He often wished it were Discworld.

“Many stories.” said Sun, “You know many origin stories. In the Garden, Eve was made from the rib. That is what the book says. That is part of the story.

After Lucifer left heaven and became the Snake, Lucifer wanted power. Adam and Eve were to be thrown from the Garden, all for eating the Apple from the tree in the center. Adam and Eve had covered themselves and were hiding. They had named the animals and plants that were present but there was no Monkey.

Lucifer Snake wept out of frustration and rage. “Eve is too weak. She is only a rib. She can’t bear the children and bear the blame for the apple as well.” One of Lucifer Snake’s tears fell into the dirt. It held some of Lucifer’s remaining power from Heaven. The tear and the dirt shuddered and…”

“What are you doing?”  Jake was standing in the sun, his shadow falling over Rick.

Rick scrambled back. “Nothing!”

“Yeah?” said Jake. “Nothing? Stupid.”

“Isn’t your show on?” Actually Jake had shows all day. He did nothing before school but watch tv and after school he alternated. TV. Movie. TV. Movie. Ever since the game platform had broken. They couldn’t afford a computer or internet right now anyhow.

“Power’s off.” Jake muttered, head down. He was kicking at a pile of dirt.

Rick knew that Ma would not get the check for another two days. Then there would be a fine to turn the power back on. It had happened twice in the last five months. Eleven foster kids and Jake, but there was never enough to go around. Ma might be able to get help from the church, but she’s said she couldn’t use it too often or they’d cut her off.

“Army,” said Jake. “I told Alf and Wheeze that they are playing too. Now.”

Rick got up. He didn’t dare look at Sun and he didn’t want to get pounded. He wanted the story. He hoped Sun would understand.

In bed in the dark, tired, he worried that Sun would not come back. They were out of bananas and really out of most things other than oatmeal. At least they had that.

And the deep voice woke him. “The tear and the dirt shuddered. I rose out of it. I didn’t know who I was or what I was for. Lucifer looked at me and started laughing. “Go to them. Go to Adam and Eve and get your name.”

Adam had done the naming, but he had fallen asleep in the terror of the Apple. I went and there was Eve. She looked at me and said, “Hello. You are Monkey.” I threw my arms around her neck and cried. My tears carried Lucifer’s power and dripped onto her shoulder. The tears entered each cell and added power, and Eve passed them down to each child.  Through the mother, only. You too have Eve‘s mitochondria.

And that is one story of how I became the Monkey.”

Rick was crying a little. He hoped Sun couldn’t tell. He didn’t remember his mother. He wished he did. And he was tired, he didn’t like playing Army with Jake and Wheeze had skinned his knee and bled and Ma had been upset. “We are out of band-aids!” She used soap on the scrape and Wheeze had cried. Rick had tried to do what Jake said without getting hurt, but he didn’t like Wheeze getting hurt either.  He was also so glad that Sun had come back that he could hardly bear it.

“Will you tell me more stories? Please?” he whispered.

“Yes,” said Sun, “Now sleep….”

Part 5  by : Austin

Part 6 by : Phaena

Part 7 : Written by Tobias

Part 8 : Written by  Priceless Joy

Part 9: Written by Raskmik

Part 10 : Written by Manvi

Part 11 : Written by Sweety

Adverse Childhood Experiences 2: Out on a Limb

We are approaching a seismic shift in psychiatry. I am now going out of a limb to predict the direction we will go in.

The allopathic medical community will resist, including many psychiatrists. But it is the neurobiologists and brain imaging and psychiatrists who will prevail. If the creek don’t rise and we aren’t hit by a giant asteroid, nuclear winter, devolve into fighting over the remaining arable land as the world heats up….

I have been thinking about this all through my career, but especially since the lecture on adverse childhood experiences, which I heard in Washington, DC about ten years ago. I wrote about that lecture on January 6, 2015. The lecturer was a woman. She said that it appeared that the brain formed differently in response to childhood adverse experiences. She said that we don’t yet know what to do with this information.

Staggering understatement. I went from that lecture to one about ADHD. The lecturer was male. He said, “Children diagnosed with ADHD have brains that are different from normal children on PET scans and functional MRIs. We don’t understand this.” He sounded puzzled. I thought, he didn’t go to the previous lecture….

Childhood adverse experiences are scored zero to seven. I score a five. I am at high risk for addiction. I assumed this when I realized at age 19 that my father was an alcoholic and my mother was enabling. I was very very careful about alcohol. I tried pot twice and didn’t like it. I refused to try anything else, and refused benzodiazepines when I was depressed: they are addictive. With an ACE score of five, I am also at higher risk than a person with a score of zero for ALL mental health diagnosis: ADHD, depression, bipolar disorder, obsessive compulsive disorder, etc. People with a score of five had a 60% chance of being diagnosed with depression compared with a 10% chance in people with a score of zero over the life of the study. In the last fourteen years I’ve only been diagnosed with a “grief reaction” which is a temporary reaction to grief. It is also called an adjustment disorder. High adverse childhood experience scores are also at higher risk for morbidity and mortality from heart disease, emphysema, arthritis, basically everything and tend to die younger.

What this means, I think, is that our brains are plastic in utero and in childhood: the wiring is put down in response to the environment. This is adaptation. I have crisis wiring: my mother had tuberculosis when I was conceived and born. Really, from an evolutionary standpoint I AM weird: babies whose mothers had tuberculosis died. Quickly. I was saved because my mother coughed blood one month before I was due. A lot of blood. She thought she had lung cancer and would die. The fetus is bathed in those stress hormones, grief, fear….

I was removed from my mother at birth to save my life. I then was removed from people at 4 months and at 9 months. I grew up trying to be independent and highly suspicious of adults.

I predict that we are going to revamp all of our ideas about mental health. The brain wiring is set up depending on the environment, physical and emotional, that the child grows up in. My friend Johanna was outraged in college when we learned that the fetus and placenta basically take over the hormones of the woman for 9 months. “I’m not letting some baby grow in me and do that!” Johanna said. “I am going to figure out how to implant the pregnancy in a cow. You take good care of the cow and you can drink beer through the whole pregnancy! The cow won’t even notice when the baby falls out!” She has three children, an MD and a PhD in genetics. She did not use a cow.

The brain wiring is an adaptation to the environment. If there is war or domestic violence or addiction or mental health problems, the child’s brain kicks in emergency wiring. This is to help the child survive this childhood. As an adult they are then more at risk for mental health disorders, addiction and physical health disorders.

In the end, the sins of the parents, or the terrible circumstances of the parents, are visited upon the children. We have to take care of the children from the start in order to be healthy.

And people who have low adverse childhood experience scores don’t understand. They grew up with nice people and in a nice environment. They wonder why people can’t just be nice. The fear and grief and suspicion and emotional responses that appear maladaptive in adults, that is what helped people survive their childhoods. That is what I remember each time I see an addict in clinic, or someone who is on multiple psychiatric medicines, or someone who is acting out.

Sleep

Our sleep doctor, a pulmonologist, gave us a wonderful update talk on sleep in early 2009.

He said, “First of all, I hate that blue butterfly.” For those who do not watch tv or read magazines in the United States, the blue butterfly was in advertisements for a sleep medicine.

“The blue butterfly lies,” he said. “Eight hours sleep is NOT normal and NOT average.”

He said the average amount of sleep for an adult is 7.5 hours. Some people need more, some people need less. I need 6 to 6.5 except on the first day of menses, when my body prefers 10-11 hours. Too much information?

“Catching up is a myth.” He said that we don’t catch up on sleep after the first night. I get people all the time in clinic who say that they haven’t slept for a month and “need to catch up.” The first night with a sleep medicine, people catch up some but that is it. After that, their body returns to their average.

Alcohol is bad for sleep. Yes, I know, it makes you fall asleep faster. However, it is not normal sleep and you will wake when it wears off, in 3-5 hours. And you may be a bit jittery and anxious, especially if you have more than 2 drinks a night routinely. Hello, I said that is the alcohol wearing off. Are you partly addicted? Tell me you can’t fall asleep at all without it? Want a pill instead?

Sleep pills are really alcohol in pill form. Really, really, really. We use benzodiazepines — that is, valium, ativan, librium, etc. for alcohol withdrawal because it has the same mechanism of action. In other words, we are substituting the benzo for the alcohol and then withdrawing you more slowly. Withdrawing from heroin or narcotics makes the pain receptors go completely gonzo, but it doesn’t kill you. It just makes you writhe with pain and wish you were dead. Withdrawing from alcohol can cause the blood pressure to go too high and can cause a stroke or seizures and kill you. So how enthusiastic am I about adding that lovely blue butterfly sleep pill to the 3-5 alcoholic drinks that someone has at night? NOT. Gosh, if we get the dose high enough, mix of alcohol and benzodiazepines the person could throw up and drown in their own vomit or just become sedated enough to stop breathing entirely and die, or just enough for brain damage. That’s fun.

And we don’t know if sleep pills are safe long term. Read the fine print. Ambien is tested and approved for use for two weeks. Right. Not 10 years. We don’t know what the hell they do to your brain if you use them for 10 years. One sleep pill has been tested for longer term use: that is, six whole weeks. Sonata. So I am stingy when it comes to sleep pills. I give people 8. Yes, 8, and tell them not to use them more often than once every three days because I am NOT going to give them 30 a month. I am going to give them 8 a month and that with reluctance. That is a conservative approach to long term use. And if they drink anything over 1-2 drinks a night, they have to cut that down first.

“But doctor, I wake up in the night!” And you are between 40 and 60 years old? That would be normal. Yes, I said normal. NORMAL NORMAL NORMAL. Ok, here’s the story. Little babies wake 4-5 times a night, right? Really. Ask any new mom or dad. Eventually they “sleep through the night”. No, actually they don’t really. They still wake 4-5 times a night but they fall back asleep really quickly and without howling. They keep doing this as children, teens, young adults, adults…..and then sometime in the 40-60 year old range the wake up periods get a little longer. And we remember them. It is normal. It is ok. Do not drug it.

“But I can’t go back to sleep.” Ok, here are the sleep hygiene rules. No violent tv or any screen time (yes, that includes computers, you addicts) for the last hour before bed. No caffeine after noon. Bed is for sleeping and sex only. If you want to read, get out of bed. A cushy armchair by the bed is fine, but get out of bed. Sorry, but you asked. Music is ok before bed and so is radio. The visual light in any screen activates weird parts of the brain, so that’s why no screen. Don’t listen to music or radio that sends your blood pressure through the roof. Exercise is best at least 4 hours before you are trying to drop off. A cool bedroom turns out to be better for sleep than a really warm one: turn down the heat and save money. Warm milk actually works.

“But doctor…” Ok, I know, you CAN’T do some part of the above. Do what you can.

“My teenager falls asleep in classes all the time.” Ah, teens are interesting. The brain essentially melts when puberty hits, at around 12, and is done with major hormonal rewiring by age 25. Teens need MORE sleep than kids or adults. 10-12 hours. They are working hard on puberty. Our sleep doctor said that the time the teen wakes up on the weekend indicates their real circadian rhythm. So, if a teen wakes at 1 pm on Saturday and Sunday, and is going to bed at two, that is where their circadian rhythm is set. Of course they are groggy as heck when they get up at 7 and trundle off to school and that history teacher is boring and drones in a monotone. How do we reset the rhythm? It takes time. The teen has to set an alarm on the weekend and get up progressively earlier. And they STILL need 10-11 hours so guess what? If the goal is 7 am, they should be going to bed by 9 pm. “HA, HA, HA, HA!” laughs the parent. Most teens are not getting enough sleep and are not catching up on the weekend. Parents can have influence. The sleep needs start to decrease as teens are entering their 20s.

Also, no screens in kids’ bedrooms. No tv, no computer, and the cell phone stays in another room. Start this with small children. Why? Kids are up texting at 2 am. Or surfing the net. Or watching whatever. It is a good sleep habit to get out of bed if you can’t sleep and go read something or listen to music. Out of bed, not in bed. Set a good example for your kids and get your television out of the bedroom….ok, now you hate our sleep doctor, not me.

What medicines do I use to help people sleep? I don’t like the benzodiazepine related drugs, which is most of the advertised New Fancy Expensive sleep medicines. I do use old medicines: antidepressants in low doses, very low. Trazodone, amitriptyline and nortriptyline. They are cheap and we are actually using the side effect; that is, they make people drowsy. I prescribe at doses way below the theraputic dose for depression.

Geriatrics. Well, it’s a difficult group. It’s not good to make someone drowsy who needs to get up at night twice to urinate and is a bit shaky on their pins and who won’t turn on the light for fear of disturbing someone. If I make them drowsy they trip and then we have a hip fracture. Mostly it is education: yes, they are waking up, maybe more than once and it’s normal. I have had people really cheer up once we’ve had this discussion. Oh, they say, I’m normal. They’ve been confused by that damn blue butterfly.

Sleep well.Moderate your alcohol, caffeine, television, computer, and cell phone; exercise, eat right, drink enough water and put your doctor right out of business. And the blue butterfly too.

revised. previously published on everything2 November 2009

Please allow me to introduce myself

I have joined blogging 101 and missed yesterday’s assignment: to introduce myself.

Hello. I curtsy, but have to look up the spelling, because I spell it curtsey initially. So: I am not a great speller.

Hello. I am a mom, divorced, with two children, one over 21 and in college and one in 11th grade.

I am a rural family doctor.

I had strep A in my lungs and muscles in June and am just now getting permission to return to work part time. I had more time to blog.

I have been writing on everything2 since 2007. My sister started there in 2001 and became an editor. She married a Brit that she met on line. He was a “god” on the site. She was diagnosed with breast cancer between when they were engaged and when they were married. She died in 2012. I only had one sibling.

I write poetry, fiction and non-fiction, the latter mostly about medicine.

I am a madashell doctor, and traveled across the US in 2009 with the Oregon madashell doctors, giving talks about single payer health care, medicare for all. The United States health system is a terrible mess, geared for profit not people. It is amazingly awful and unfair. My sister had all the care in the world because she worked for Cal-trans, so was part of the largest Union on the planet, the California state government union. But she could have worked elsewhere, lost her job, lost her health insurance and died much sooner.

I have a cat and a fish.

I am very interested in the sufis and the zen buddhist teachings and some of my poems reference the Beloved.

Thank you.

http://madashelldoctors.com/

http://everything2.com/

<a href=”http://Blogging U.” title=”Blogging 101: Introduce yourself”>

Adverse Childhood Experiences

I went to a sparsely attended lecture about the Adverse Childhood Experiences Study, or ACE Study, in 2005 and it blew my mind. I think that it has the most far reaching implications of any medical study that I’ve read. It makes me feel hopeful, helpless and angry at God.

The lecture was at the American Academy of Family Practice Scientific Assembly. That year, it was in Washington, DC. There are 94,000 plus Family Practice doctors and residents and students in the US, the conference hall had 10,000 seats and the exhibition hall was massive. At the most recent assembly, there were more than 2600 exhibitors.

I try to attend the lectures numbered one through ten, because they are the chosen as the information that will change our practices, studies that change what we understand about medicine.

The ACE Study talk was among the top ten. Yet when I walked in, the attendees numbered in the hundreds, looking tiny in three joined conference rooms that could seat 10,000. The speaker was nervous, her image projected onto a giant screen behind her. My experience has been that doctors don’t like to ask about child abuse and domestic violence: I thought, they don’t want to go to lectures about it either.

The initial part of the study was done at Kaiser Permanante, from 1995-1997, with physicals of 17,000 adults. The adults were given a confidential survey about childhood maltreatment and family dysfunction. A simpler questionnaire is at http://www.acestudy.org/files/ACE_Score_Calculator.pdf, but it is not the one used in the study. Over 9000 adults completed the survey and were given a score of 0-7, their ACE score. This was a score for childhood psychological, physical or sexual abuse, domestic violence, or living in a household with an adult who was a substance abuser, mentally ill or suicidal, or ever imprisoned.

Half of the adults reported a score over 2 and one fourth over 4. The scores were compared with the risk factors for “the leading causes of death in adult life”. They found a graded relationship between the scores and each of the adult risk factors studied. That is, an increase in addiction: tobacco, alcohol and drugs. An increase in the likelihood of depression and suicide attempt. And an increase in heart disease, cancer, chronic lung disease, fractures and liver disease. The risk of alcoholism, drug addiction and depression was increased four to twelve times for a score of four or more.

The speaker said that the implications were that the brain was much more malleable in childhood than anyone realized. She said that much of the addictive behaviors and poor health behaviors of adults could be self-medication and self-care attempts as a result of the way the brain tried to learn to cope with this childhood damage.

I left the lecture stunned. How do I help heal an adult who is smoking if part of it is related to childhood events? From there I went to a lecture about ADHD, where the speaker said that MRIs and PET scans were showing that children with ADHD had brains that looked different from children without ADHD. I thought that speaker should have come to the other lecture. And I did not much like my ACE score, though it does explain some things.

I feel hopeful because we can’t address a problem until we recognize it.

I feel helpless because I still do not know what to do. The World Health Organization has used the ACE Study in their Preventing Child Maltreatment monograph from 2006. But it is not very cheerful either: “There is thus an increased awareness of the problem of child maltreatment and growing pressure on governments to take preventive action. At the same time, the paucity of evidence for the effectiveness of interventions raises concerns that scarce resources may be wasted through investment in well-intentioned but unsystematic prevention efforts whose effectiveness is unproven and which may never be proven.”

Do I do ACE scores on my patients? With the new Washington State opiate law, we do a survey called the Opiate Risk Tool. It includes parental addiction in scoring the person’s risk of opiate addiction. But not the rest of the ACE test. At this time, I don’t do ACE scores on my adult patients. I don’t like to do tests where I don’t know what to do with the results. “Wow, you have a high score, you will probably die early,” does not seem very helpful. But I remain hopeful that knowledge can lead to change. And it makes me more gentle with my smoking patients, my addicted patients, the depressed, the heart patient who will not exercise.

I am angry at God, because it seems as if the sins of the fathers ARE visited upon the children. It is the most vulnerable suffering children who are most damaged. That does not seem fair. It makes me cry. I would rather go to hell then to the heaven of a God who organized this. I stand with the Bodhisattva, who will not leave until every sufferer is healed.

1. ACE study   http://www.cdc.gov/ace/about.htm

2. American Academy of Family Practice   http://www.aafp.org/events/assembly.html

3. ACE questionaire   http://www.cdc.gov/ace/questionnaires.htm

4. Score correlation with health in adults   http://www.ajpmonline.org/article/PIIS0749379798000178/abstract

5. WHO preventing child mistreatment   http://whqlibdoc.who.int/publications/2006/9241594365_eng.pdf

6. Washington State Opiate Law   http://www.agencymeddirectors.wa.gov/

7. Opiate Risk Tool   http://www.partnersagainstpain.com/printouts/Opioid_Risk_Tool.pdf

First published on everything2 November 2011.