Monthly Archives: November 2017

by

containment in ceremony

This is for Taleweaver #147 – What brings you joy?

My minister talks about containment in ceremony.

That the ceremony can be a container for us to handle our worst selves and our best selves safely.

The Catholic mass is an example, particularly when it was in Latin. That it takes us through horror and suffering and death and then resurrection. This past weekend we performed the Mozart Requiem, from grief through joy.

My minister says that Western Civilization has lost the container for spirituality in the churches and instead holds the sacred in a love relationship. He says that the projection of one’s best self on the loved one can then flip into the projection of one’s worst, if we are not careful. We are attracted to people who have some of the aspects that we hide in our unconscious, so these are activated and projected. We magnify the talents and the beauty and wisdom of the love object. They are not real. True love is when we can slowly withdraw the projection and see the actual person who is there and then really love them.

I am taking a class where we are reading The Maiden Tsar. I am thinking of the chicken feet that Baba Yaga’s house stands on. We say that a person is chicken when they are afraid and won’t go forward, a coward. So Baba Yaga’s house on chicken feet: it is a house of fear, fear alive, terrifying. And what do we find in this most frightening place? We find that that our culture has most devalued: an old woman, not beautiful, not fertile. And she cares nothing for logic. In order to meet her challenge and not be destroyed, we must use our intuition, not our logic. No linear thinking, but a respect for magic and for humor.

I am thinking of the grandmother theory, that women have a dramatic menopause because they are the tribal memory. They have to survive the famine, raise the grandchildren, remember where there might be food, remember tricks and things forgotten. A useful man may remain fertile for the tribe, but a useful woman loses hers, because she is now a walking repository of knowledge. And western civilization has denigrated and ignored her: so she lives in the house with chicken feet.

My children are now adults but they do not have children yet. I am a practicing grandmother though. I am living alone for the first time in 28 years. I practice on other people’s children. A two year old loves my house: there is a stick dragon in the closet that roars if you press his throat. There are toys that he can’t take home. “That is mine. You may play with it while you are visiting.” I put a towel on the floor and get the espresso set out. I have never made espresso. He sits on the towel and pours water from the coffee pot until the cup overflows, the saucer overflows, the towel is soaked. He looks up at me, holding the coffee pot. “More?” I say. He hands it to me and I fill it with water again. His mother is surprised that he is wet from head to toe when she picks him up. By then the towel is cleared, the coffee set is drying, and he and I share a glance, our secrets safe. Until the next visit.

by

hypertension: The 2017 Clinical Guidelines

A visual guide to the new hypertension guidelines: https://www.medpagetoday.com/cardiology/hypertension/69399
In writing: http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults
I don’t watch television news, so I always hear about these things from patients first. “What do you think of the new hypertension guidelines?”

“Haven’t heard about them yet, so I don’t know.” Seems pretty embarrassing really, doesn’t it? Shouldn’t I be alerted as a doctor before it hits the news?

First of all, these guidelines are NOT JNC 9.

What is JNC 9, you ask?

One of the messy complications of medicine for people in the US and in the world, is that there is not ONE set of guidelines. There are multiple sets of guidelines. Take mammograms, for example. The US Preventative Task Force* said that the evidence in their review could not differentiate between yearly and every other year mammograms. They said you could do it every other year. The American Cancer Society and the Susan Koman Foundation yapped and had different guidelines, do it yearly. So as a physician I have to not only pay attention to the guidelines but know who is putting them out. The radiologists wanted yearly mammograms too, surprise, surprise.

And do you think some of it is driven by money? Well, it’s the US.

JNC 8 is the Eighth Joint National Committee and put out guidelines in 2014. Their job is to review all of the big hypertension studies since JNC 7 and put out new guidelines. JNC 8 took over a year, was multidisciplinary, and the final document was 400+ pages.

They said that if a patient was over 60, their blood pressure should be taken standing up, and the goal was under 150/90. Under 60, sitting, goal under 140/90. Normal is 120/70 and below.

Then there are pages and pages of recommendations about which medicines to use and in special circumstances, that is: diabetes, kidney failure, heart disease, atrial fibrillation, etc, etc.

The cardiologists promptly started yelling about how JNC 8 is wrong and they put out a huge study saying that people have less heart attacks if their blood pressure is 125/80 or below.

But… the heart is not the only organ in the body. My patients are 77% over age 50 and 48% over 65. Once a person hits 80, their blood pressure may drop when they stand up. Most do. And low blood pressure, well, it’s bad for the over 80 crowd to get poor blood flow to the brain or to the kidneys or to faint and break things. That is why JNC 8 is multidisciplinary: because we need geriatrics and psychiatry and ortho and family medicine to be part of the guidelines.

So these NEW and IMPROVED guidelines. Well, who is putting them out? American Heart Association, American College of Cardiology, and a bunch of other mostly heart related organizations. And they are comparing it to JNC 7, not JNC 8. JNC 8 is being ignored. This document is a mere 192 pages, with the “short” version being 112 pages.

It says that blood pressure 130/80 to 140/90 is stage I hypertension, not prehypertension, and that we should treat it with lifestyle changes. Drugs are still to be recommended at anything over 140/90, though honestly, I start with lifestyle there too. Over 180/120 is now “hypertensive crisis”, consult your doctor immediately. 140-180/90-120 is stage II hypertension.

How will this change my practice? I am still thinking about the new guidelines and who has skin in the game. The AAFP (American Academy of Family Practice) put out a link to the guidelines and then a cautious comment to the effect of “We are studying how we should respond to this.”

Before this came out, I would tell people the JNC 8 goals. I do stand the people over 60 up, most of the time. I also tell people that the cardiologists want their blood pressure lower. And then that the cardiologists mostly ignore hypertension and cholesterol guidelines anyhow. If I follow the guidelines and then the patient sees a cardiologist, the cardiologist usually changes something. Guidelines be damned.

It comes down partly to a patient’s goal. I have people come in and say, “I don’t want to die of dementia!!” I see that as an opening. “What DO you want to die from?” People have different ideals. Some say, “I don’t want to die!” but then many do think about it. Sometimes this changes their ideas about what they want treated and what they don’t want treated.

Not everyone’s blood pressure drops in their 80s. Some people develop hypertension in their 90s. I tell them. They say, “I’m not taking a drug!”

I reply, “Let’s talk about strokes.”

They usually are not afraid of sudden death, but they don’t want the disability of a stroke. Many choose medicine after all.

One of the issues with guidelines is complexity. I could spend 20 minutes with a patient just talking about hypertension guidelines and choices of drugs and side effects and why they should be on an ace inhibitor or ARB if they have diabetes…. and there are guidelines for EVERYTHING. Sometimes conferences feel like all the specialists yelling: only half of diabetics are controlled, only one third of hypertensives are controlled, family doctors aren’t screening for urinary incontinence enough, osteoporosis, lung cancer, stop smoking! And then what my patient really needs is to talk about their adult child, in jail for addiction, and how frightened they are about overdose and the grandchild and the future…..

JNC-8 flowchart: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf
JNC-8: https://jamanetwork.com/journals/jama/fullarticle/1791497
*lots of guidelines: https://www.uspreventiveservicestaskforce.org/