Monthly Archives: January 2023

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On a bus

I am in a bus. The driver is a man and quiet. It is night and I can’t see much besides road. I am standing by him.

“You have strong emotions.” he says.

“I am so glad that I can be myself with you and not hide them.” I lean my cheek against the back of his right shoulder. He doesn’t answer but what I feel is acceptance.

I wake up. It was a bus but I don’t know what or who else was on it. I don’t know where it is going. I am worried that I did not have a seatbelt on and I am just standing in the front of the bus. Unrestrained. Unrestrained emotion?

Once a woman says to me, “Your emotions are too strong.”

I think, “My emotions are too strong for YOU. They are normal for ME.” I avoided any discussion of emotion with that person for two years.

The people in dreams are aspects of ourselves. The quiet man is an aspect of myself and he is driving the bus. Emotion riots around but is not driving. Life is rather like that bus. We don’t always know where we are going or what is next.

I have had a very medical January, working to help three other people. I talk to another friend yesterday. She says, “You are being called back to medicine.”

I frown at the ceiling since I am on the cell phone. “I guess so. I am thinking about how I want to do it. I don’t know yet.”

She is off on a trip for three weeks. “You’ll figure it out.”

And where will the bus take me next?

I wish I had an ambulance that unfolds into a clinic.

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I had rather a grand time pulling out action figures and dolls from the basement to set up scenarios with the Barbie Ambulance. Here the baby has a facial rash. Probably 5th disease, parvovirus. This baby’s rash resolves when you wash her face with cold water. I am pleased that Barbie Doctor has a mask.

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Long Covid healing crash

I have a friend with Long Covid. Eight months now.

My friend describes blood sugar crashes. She does not have diabetes and was tested before Covid. She has not been tested again.

“Sometimes I eat dinner, feel better, and then an hour later I feel terrible again. I have to eat again. And I ate extra in November and all that happened is I gained ten pounds. So eating extra doesn’t work.”

I suspect that as the clue: the feeling terrible an hour after she eats.

I call her the next day: “Spread the carbohydrates out. It could be that your body is producing too much insulin, storing the glucose and carbohydrates, and then your blood sugar gets too low. That can happen early in type 2 diabetes, but this could also be a healing mode.”

I write about carbohydrates to her. Anything that is not a fat or a protein is a carbohydrate. So all the grains and all the vegetables and fruits have carbohydrates, sugars. Glucose, fructose, maltose, lactose. Milk products contain lactose, but also fat and protein. Avocados are weird fruit and mostly fat. Sugar beets and peas are high sugar vegetables. A small apple is 15 grams of carbohydrate and a large one is 30. A tablespoon of sugar is also 15 grams of carbohydrate. A coke had 32 grams and a Starbuck’s mocha has over 60 grams. I quit drinking them when I looked that up. Empty calories.

A cup of kale has only 7 grams of carbohydrate for our bodies. The rest is fiber that we can’t break down into sugars. Fiber doesn’t raise our blood sugar. I wonder about cows with their four stomachs: they can break grass down into food and we can’t.

At any rate, my friend is going to try 3-4 meals a day with only 30-45 grams of carbohydrate and three snacks, at 15-30. This is an athlete and young. Most of my patients were closer to 70, so would need to do the lower end of those numbers.

I had crashes after my second and third pneumonias in 2012 and 2014. Strep A pneumonia and strep throat of the muscles. It hurt, like all over Strep A. After the 2014 one, it was six months before I could go back to work. When I did, it was exhausting. I was only seeing 3-5 patients a day at first and could barely do that. I ate one meal a day because food crashed me. As soon as I ate I went to sleep. My MD did not believe me. I saw a naturopath too. She claimed it was a food allergy and I said, “I don’t think so. I think it is a healing crash. I think my body is doing a ton of repair work and wants me asleep and not moving much.” Over the next six months it slowly improved. I went to 2 meals a day. Since then I really do not eat until I have been up for 4-6 hours. Expect tea with milk. And yes, I am getting a little nutrition through the milk, fat and protein and lactose.

I had one patient who said eating made her faint. I didn’t know what to do, but she was in the ICU, ate lunch and then fainted into her tray. The nurse was standing right there and immediately did a blood sugar and called me. Her blood sugar was in the low normal range. We transferred her to Virginia Mason in Seattle. She came back with a diagnosis that seemed pretty much like hand waving. Idiopathic (meaning the doctors dunno why) central (ok, brain) something syndrome, which meant yeah, she faints after she eats and doesn’t have diabetes and that is weird.

I am reading about similar neurological symptoms with Long Covid and also POTS: postural orthostatic tachycardia syndrome. This translates to heart rate goes faster than it should when the person stands up. Again, the cause is not clear and it’s not clear how to fix it.

Once an older patient went to the neurologist to discuss getting dizzy when she stood up. She returned grumpy. “He said that I just have to stand up slowly because I am 80. I don’t feel like I’m 80. I want to hop out of bed like I always have. But if I do, I nearly faint.” Her body was taking longer to equilibrate blood pressure after she stood up. The neurologist said no medicine: stand up slower. She grumpily complied.

I told my friend that maybe the pancrease is stressed and producing too much insulin. To store food. But another possibility is that her body wants her to lie down and rest so that it can do healing work after eating. This would make any young person impatient, but sometimes we have to listen to our bodies. I have learned THAT the hard way.

Blessings.

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The photograph is of a Barbie ambulance/clinic. It does have a gurney, but the back opens up to be a fairly well appointed clinic, with lots of details, including a television in the waiting room. Today the doctor has wings. Fairy? Angel? We are not really sure.

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DIY FUD

I am Elwha, cat.

My mother has changed. For the first year she fed us many times a day, but now she is nefarious. She left for three weeks and a man came in daily. He fed us but less generously. She now feeds us twice a day and less than in the past.

I make offering to the gods in hopes of more food, that the gods will influence my mother and turn her good again.

I place the mouse effigy in my bowl. A mouse would be delicious and if alive it would be delightful fun as well! We watch the birds out the windows and long to catch them.

There is no response from Mother or the gods.

I try again.

Another mouse, a symbol of technology, that sponge that she removes fur from furniture. Mother seems to love technology and will not let me lie on the warm keyboard. She lets me have this technological marvel. I have chewed it but it is not nutritious and gives me nothing. There are wires inside. It is fun for play but not edible.

I will wait and hope that the gods influence my mother and that more food is forthcoming.

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For the Ragtag Daily Prompt: nefarious.

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Music Magnifies Joy

Ben Sollee is new to me. I heard him at Over the Rhine‘s NoWhereElse Festival. In Ohio.

What a fabulous line up of musicians! Ben Sollee makes joyous music with a cello, his voice and a drummer! They made more noise and more complex rhythms than many much bigger groups! I got one of his albums and three other fabulous groups!

This is lovely:

All things shall perish from under the sky, music alone shall live never to die.

For the Ragtag Daily Prompt: magnify.

The photograph is of another group at the festival: Carolina Story.

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Doing the best with what you have

Medicare doesn’t cover everything.

It can’t. There are new things being thought up all the time. Some are legitimate and some are scams. There are tons of quack medicine videos and supplements and stuff on line.

But there is also a matter of personnel and resources. Sometimes we do not have enough. Then we have to do the best we can with what we have.

There is a particularly difficult case from my second year of rural Family Medicine with Obstetrics. Things went right but just barely. This is from memory and over 25 years ago, in the 1990s, so I can’t violate hipaa because I can’t remember names from then. Mostly.

I had a pregnant woman whose pregnancy had gotten complicated. Her ultrasound showed an abnormal placenta. Very rarely, the placenta can grow into the uterus too far, and form a placenta increta. Even more rarely it can grow THROUGH the wall of the uterus and into another body part. That is called a placenta percreta.

In this case we thought that the placenta had grown into the bladder. We were not certain. The obstetricians were aware. Our patient was aware. A cesarean section was planned for when the fetus was mature.

Then she developed a second pregnancy complication. Preeclampsia. This is a complication where blood pressure rises, there is protein in the urine and many things can go wrong. It can progress to eclampsia, which means seizures. This is Very Bad, which means the mother and fetus can die.

She developed HELLP syndrome. This is an acronym. The P is what I worried about, platelets. Platelets help your blood clot. Her platelet count was dropping out of sight. We were rural, 180 miles from the nearest high risk obstetrician. We did have blood for transfusion but NO PLATELETS.

The treatment for preeclampsia with HELLP syndrome is to deliver the baby. I called our obstetrician the minute I got the lab result. “No platelets — can I fly her out?”

“YES! FLY HER OUT!”

Transfer to a bigger hospital with facilities for a premature infant and with platelets, because she needs a cesearean section and she could need a hysterectomy if that darn placenta has grown through. Messy.

Problem number three: weather. We are in Alamosa, Colorado, at 7500 feet, which is the valley floor. We are surrounded by 14,000 foot peaks with passes in four directions. That nearest hospital with platelets is 180 miles and over a 10,000 foot pass and it is snowing.

I call Denver first. 250 miles. Fixed wing life flight. Nope, the weather is too bad to the east and north.

I call Albuquerque. 250 miles. Nope, the pass is socked in, the plane can’t get through.

I call Grand Junction. About the same distance. They say “WHERE are you?” I’ve never tried to send anyone there before. They demur and I cajole and beg. “Okay, okay!” The high risk obstetrics doctor can’t be looking forward to meeting this patient, but they accept.

From the start of calling to the arrival of a plane and crew usually takes about four hours. I want to chew my nails.At last I hug my patient goodbye and they go.

I get the call about 6 hours later. Delivered and they did have to do a hysterectomy, but mother and baby are fine. Her bladder was untouched. They had platelets.

Whew! I was so happy, and mom and baby too. Let’s give credit to my patient too: she got prenatal care. She paid attention. She knew she was high risk. I had told her to come in if anything changed and she did, so we caught the preeclampsia on time.

But it could have gone wrong in all sorts of ways. We were both careful and we were lucky. If the storm had been over Alamosa we would have done the best we could then, too, but it could have turned out quite differently. And thanks to the high risk obstetrics doctors who accept complex patients that they have never seen from rural doctors like me!

Blessings. Blessings on all the nurses and doctors and midlevels and hospital housecleaners and security and lab workers and the Life Flight personnel and First Responders and everyone who has worked and worked and worked through the pandemic.

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I took the photograph in Maryland in December: abstract and complicated water, ice and reflections.

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Medicare Disadvantage

Medicare Advantage plans, from for profit insurance companies, are being rebranded Medicare Reach.

They seem like a good deal. They are if you are healthy forever! So what is the catch?

In Michigan I go to look at a nursing home with a friend. The administrator shows us around. Small rooms with two beds. We also look at an assisted living. Much larger rooms, the friend can stay overnight in the private room with the parent, at a cost of $4000.00 per month. Her insurance will not cover it.

But back to the nursing home. The administrator tells us that it’s good that her parent does NOT have a medicare advantage or medicare reach plan. “It is nearly impossible to get the insurance companies to approve a rehabilitation stay at a nursing home.”

“Really?” I say.

“Oh, really.” She says. “The insurance companies certainly don’t want you to know that when you buy their “deal”.”

So, the for profit insurance companies want you if you are of medicare age and are well. BUT the catch is that they really don’t want to cover if you are sick. Think carefully before you buy a pig in a poke!

Physicians for a National Healthcare Program is working to stop the insurance companies from skimming profit off the healthier elders and then abandoning them when they are not healthy. I wish that the United States citizens would clue in, get mad, and vote for single payer! Write your congresspeople and put pressure on them! They listen to money but in the end, they live by votes. Make sure you look at the fine print, because the insurance company is there to make a profit off you, not preserve your health.

The picture is Mordechai, our plastic clinic skeleton, distrusting Profit-Over-Health Insurance Companies.

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Long Covid and overdoing II

I overdid a bit yesterday too.

Friends drove me to the airport when I wasn’t really strong enough on my own. It is two hours away at least. I am very very grateful. They kept my car. I drove them to the ferry and picked one of them up last Friday. My friend L said my brakes were suspect. Two days ago I drove to his house and he took a look. I mostly held a flashlight. The front brakes are fine but the back shoes were down to very thin. I got a crash course in brakes (2006 Scion, a very useful black box of a car) and we took the drums to be ground. We ordered brake shoes and the kit of annoying springs and things.

Everything was ready yesterday so he picked me up. I held the flashlight and then held the back of the pin for one particularly annoying and difficult set of springs. He is a very good mechanic, though not primarily cars. A cell phone picture of the brake before taking it apart and studying the intact one: useful tips. He also pointed out the blue paint. Someone added that in order to keep it all straight. We got it all back together and then tested them. It did need some tweaking to tighten the emergency brake to working order again. I got home at about 4:30pm. Whew!

So today I am tired again and rather achy, but not too bad. I may attempt a quiet day, though we never know what will happen. The best laid plans can be altered at any moment. I hope to recharge my energy today!

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For the Ragtag Daily Prompt: recharge. And speaking of recharging, here are two experts: