Monthly Archives: June 2022

by

Covid-19: Long Haul III

The CDC has guidelines for Long Covid and it can qualify for disability in the United States.

Here: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html

And here: “As of July 2021, “long COVID,” also known as post-COVID conditions, can be considered a disability under the Americans with Disabilities Act (ADA). Learn more: Guidance on “Long COVID” as a Disability Under the ADA, Section“

Here is the list of “most common” symptoms from the CDC:

General symptoms

  • Tiredness or fatigue that interferes with daily life
  • Symptoms that get worse after physical or mental effort (also known as “post-exertional malaise”)
  • Fever

Respiratory and heart symptoms

  • Difficulty breathing or shortness of breath
  • Cough
  • Chest pain
  • Fast-beating or pounding heart (also known as heart palpitations)

Neurological symptoms

  • Difficulty thinking or concentrating (sometimes referred to as “brain fog”)
  • Headache
  • Sleep problems
  • Dizziness when you stand up (lightheadedness)
  • Pins-and-needles feelings
  • Change in smell or taste
  • Depression or anxiety

Digestive symptoms

  • Diarrhea
  • Stomach pain

Other symptoms

  • Joint or muscle pain
  • Rash
  • Changes in menstrual cycles

There are recommendations for a work up by physicians. Depending on symptoms, this may include labs, ECG, echocardiogram (heart ultrasound), CT scan and other tests.

A friend has just gone through those four tests . They are “normal” except for her heart rate. At rest her heart rate is 70 with a normal oxygen level. Walking, her heart rate jumps to 135. Over 100 is abnormal in this athlete who is NOT exerting heavily.

So WHAT is going on with NORMAL testing? I think this is “Covid-19 Viral Pneumonia”, a complication of Covid-19, just as “Influenza Viral Pneumonia” is a complication of influenza. Ralph Netter MD has an illustration of lungs from a person who died of influenza viral pneumonia: the lungs are swollen and inflamed and bruised. WHY is the testing “normal” then? The swelling is throughout the lungs, so a chest x-ray sees it as all the same density and a CT scan also sees it as all the same density. The lungs may have mildly decreased breath sounds, but the sounds are even throughout the lungs. The useful TEST is a walk test. I have tested patients with “walking pneumonia” in clinic for years: get a resting heart rate and oxygen level. Then have my patient walk up and down the hall three times and sit back down. Watch the heart rate and oxygen level. If the heart rate jumps 30 beats up or is over 100, the person needs to continue rest until the heart rate stays under 100 or jumps less than 30 beats. It is important to observe the heart rate until they recover. Sometimes the oxygen saturation will drop as the heart rate comes down, and some people qualify for oxygen. Steroids do not seem to work for this. The length of time to healing is not totally surprising, because a lobar pneumonia that is visible on chest xray takes 6-8 weeks to fully clear. It is not too amazing that a bad walking pneumonia could also take 6 weeks or more to clear. If the person returns to work too soon, they prolong the lung inflammation and they are at risk for exhaustion and for a secondary pneumonia. The treatment is REST REST REST and support.

Do they need oxygen? Currently oxygen is covered only if the person’s oxygen saturation drops down to 88%. However, I think that oxygen would help recovery and make them less exhausted. With my first walking pneumonia, which was influenza, my walking heart rate was 135 and my resting heart rate was 100. Both were abnormal for me. Neither I nor my physician could figure it out. This was in 2003. I did look in my Netter book: I took one look at the painting of the influenza lungs and shut the book. “Oh.” I thought. “That’s why I can’t breathe.” The image is here, though I wish it were bigger.

It took two months for my heart rate to come down, the lung swelling to improve, and me to return to work. I read the text of Dr. Netter’s image a year later and then I read an entire book about the 1918-1919 influenza. Since then I have walked people who come in complaining of exhaustion after a “cold” or “bad cough”. Viruses can cause this and so can bacteria: mycoplasma pneumonia, chlamydia pneumonia, pneumococcal pneumonia, legionella and strep A. If the fever is gone, the infection has probably resolved, but it still can take days or weeks for the lung tissue to recover.

For Covid-19, I would add a third test: walking with weights. We test cardiac patients by asking if they can carry two bags of groceries up a flight of stairs. That is 3 Mets, a measure of the heart load. We need to measure the lung load as well. If the lung tissue is swollen, the amount of airspace is cut down and can be half normal. The heart attempts to take up the slack. The person may tolerate a heart rate of 135 for a while, but it is like running a marathon. If they are older or have heart disease, this can trigger a heart attack. I would walk the person carrying hand weights, and see the recovery.

Also, brain fog is unsurprising. If your oxygen level is borderline, it is darn hard to think. I write really strange songs when I am hypoxic. I get goofy and feel weird. The fast heart rate also feels like anxiety: I think that the body is trying to tell me to rest.

The definition of Long Covid is symptoms after 30 days. Please see your physician if you are still ill and continue to have symptoms.

Blessings.

Here is a recent article about T-cells and inflammation in the lungs of Covid-19 patients: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8460308/

and this: https://www.frontiersin.org/articles/10.3389/fimmu.2020.589380/full

by

Achievement

My first achievement for today’s Ragtag Daily Prompt is spelling achievement. And no, I did not spell it correctly on the first try.

My daughter has finished her first two years of teaching eighth grade, during Covid-19. She taught remotely until March of 2021 and then in person. She worked on her teaching certificate the first year and finished her Masters last month. She is SOOOO amazing!

Hooray for ALL of the teachers who continued to teach during Covid-19, remotely, in person, hugs and prayers and sending love.

by

Robust healthful manhood

The photograph of “a healthy man” to go with my Ragtag Daily Prompt conflate post.

I LOVE the caption. “Robust healthful manhood is the source of mental and physical power.” How differently the author portrays health womanhood, as shown in the conflate post. The book is Macfadden’s Encyclopedia of Physical Culture, in three volumes, 1911. Volume I is 500 pages. It is easy to read but it’s a different style from now. Here:

As a rule, if you will simply retain the idea that food should be swallowed at all times without effort, that is, that never, by any means, wash it down with water, milk, tea or any other liquid, that you should masticate it until it seems to disappear without swallowing, you can rest assured that you are masticating sufficiently. p. 97, volume I.

I plan to read the entire set. I think I will find lots of wonderful words for the Ragtag Daily Prompt (hey, I don’t think we’ve used masticate yet!) and material to write about.

Are there still interesting medical ideas out there? Oh, yes. LOTS. Only now they use the internet. I have subscribed to some of the series of videos, telling people how bad and wrong minded allopathic doctors are. Sigh. We do our best. The scam is that they let folks watch one a day for a week, or let them watch one, and then want you to buy the series. “Only $349.99!” Nice scam that is proliferating rapidly. I have now gotten emails saying “Health coaches should make as much or more than physicians and we can teach you how to market and target people and make that money.” Ugh and ick. Really?

I have patients in clinic who present by saying, “I don’t usually go to MD doctors, I go to a naturopath, but I am here because I need an antibiotic.”

I learn to respond gently. “Oh. If you need an antibiotic, maybe you have signs of infection? What are your symptoms?” I have to get past their dislike of allopathic medicine and find out what the symptoms are. Usually if I can diffuse them by getting the story, we can work together. Once in a while it doesn’t work: I have people come in and give me orders. “Do these labs.”

“Uh. Where did this list come from?”

The answer could be a video (by a naturopath, a biochemist, a biologist, whatever. I have watched some of these series. They start by saying that doctors are wrong/stupid/stubborn/misguided/etc.) or a “cash only” doctor or a magazine.

“Why are you coming to me?”

“I want medicare/my insurance to pay for it. I have done my research.”

“Well, medicare does not work that way. I have to list a symptom or diagnosis code for every lab ordered.”

“WHAT?”

I try to be patient. “Every lab has to have an attached appropriate diagnosis code or medicare will not cover it. There is a place in town where you can order your own, but it does not take medicare. You pay for it.”

“Just order it!”

“No. I am a medicare/insurance provider, which means I have a contract with them. It would be fraud and illegal to make up codes. Does your cash only provider use diagnosis codes? Can your bring their clinic note to me?”

One person replies, “My provider doesn’t take notes.” Oh, how nice. That provider does a very expensive panel of labs three times a year that the person is paying for out of pocket. “My provider checks EVERYTHING.” Um, and makes a boatload of money off you too, I think. That patient is very angry that I won’t take her orders and switches clinics. Oddly enough, this does not break my heart.

Some days I hate Dr. Google. There are lots of websites and people on line swearing that they can improve your health. There are scientific looking papers that swear something has been tested, but read the fine print: if the sample is 8 people, how does that stack up against the Women’s Health Initiative, where one arm of the study had 27,000 people? The evidence is weighted. We get multiple articles in medical school and subsequently about how to read a paper, how to weigh the evidence, how to recognize fraud or a poorly designed study.

I do not object to people looking on the internet and I have had people who came in and said, “Is it possible that I have THIS?” and who are correct. However, I see more fraud, always.


by

rural doctoring

I read Grampa’s Solo Visits this am and it makes me laugh.

Since I have been a family doctor in my town of 9000 for 22 years, the grocery store and coffee shops can be interesting. When I moved here, my daughter was two and my son was seven. We have three grocery stores. I usually go to the one 7 blocks from my house. I would see patients. My diabetics would sometimes look guilty and scurry away when they saw me. Another patient comes to peer in my cart.

“I want to know if YOU are eating healthy food.” he says.

I laugh.

“I don’t see any vegetables.” he says.

“I am in a CSA,” I say. “I get a box from the farm once a week.”

He frowns. “Do you get to choose?”

“No,” I say. “But since I hate throwing vegetables out, we eat more vegetables. Also, we eat ones that are unfamiliar. The first time I got celery root, I had to look it up. I didn’t know what it was.”

He nods. “Hmmm. Ok. We want to be sure you practice what you preach.”

I laugh again. “I sneak in to get the ice cream at midnight, ok? And where is YOUR cart?”

“My wife has it,” he says. “You don’t get to see it.”

“Ok, then. Have a great day.”

When we were first in town, occasionally someone would come start talking about their health in a store.

“I can’t discuss your health in front of my children. HIPAA.”

“Oh,” they’d say, “Uh, yeah. I should call the clinic Monday?”

“Yes, please.”

We had a coffee shop that made the best pastries that I’ve had since I was an exchange student in Denmark. I wished they’d make tiny pastries, bite size, for the diabetic folks. Those folks would slide a newspaper over their plate when I walked in with my family. They looked terribly guilty. I might nod, but I wouldn’t say anything. Sometimes they would confess at the next visit.

There are lots of jobs in small towns where people are very much public figures. Not just doctors, but the people who work for the city and the county, the ones who redo the taxes for homes, the realtors, all sorts.

After I was divorced, another doc at the hospital asks, “Dating someone new?”

I frown, “How do you know?”

She grins, “He lives on my street. I saw you.”

Dang it. The rumor mill is very very efficient and can often be fabulously wrong. That time it was correct, though I don’t think she passed it around. Other people live on the street.

A few days ago someone that looked familiar walks by me. “What are you doing with so-and-so?”

I laugh. “Rumors abound.” I say. “You would not believe the rumors!”

I took the photograph of the coyote yesterday, driving home. Stopped dead in my lane, no one else on the road. People will be stopped in the road here, talking to each other in two cars going opposite directions, or talking to a friend on foot.

by

Volume of water

We check the tides before we go walk the beaches on the Olympic Peninsula. I am learning the patterns of the tide locally. On North Beach, the tide is about an hour later each day. However, low tide is at a different time further out the Olympic Peninsula. I had to think about that a bit.

Picture the tide a low with the Salish Sea volume down. Then the tide turns and starts flowing back in. The Salish Sea is like the roots of a tree, with a main trunk and then branches and branches and more branches. There is water coming in from the land, from streams and from rivers, but the tide rolls in from the trunk first and then spreads through all of the roots. I have a tide table for the peninsula for this year, and it has tables for multiple different sites! Most days we have two high and two low tides, but once in a while the low goes out so little that it matches both highs, and we only have two tides that day, a high and a low!

I took the photograph at Dungeness Spit this month. The tide was nearly low when we started walking and we only went 2-3 miles down the spit and turned back. It is beautiful! Check the weather, check the tides and always take something rain proof, even in July. Our water is not warm.

For the Ragtag Daily Prompt: volume.