bravery

There is more than one list of seven virtues. Courage, or bravery, goes back to Aristotle and Plato as one of the four cardinal virtues.

What is bravery to you? An extreme sport? A warrior?

My sister endured cancer treatment for 7 years, over 30 rounds of chemotherapy. She said, “People say I am brave, but they don’t understand. I don’t have a choice. It’s do the therapy or die.” It’s still brave, though, isn’t it.

The person who comes to my mind for bravery is a woman, a long time ago. She spoke Spanish and we had a translator. Her son had had rheumatic fever and they had gone to the pediatric cardiologist for the yearly visit. Her son had a damaged heart valve that was getting worse. He was somewhere between 9 and 12.

“The heart doctor says he needs surgery. He needs the valve replaced. But the heart doctor said he could die in surgery.” she said.

I read the notes and the heart ultrasound. “The heart valve is leaking more and more. If he doesn’t have the surgery it will damage his heart. He will be able to do less and less and then he will die. If he has the surgery, there is a small chance that he will die. But if he doesn’t, he will be able to grow and to run and to be active.”

She said, “I am so afraid.” But she returned to the pediatric cardiologist. And he got through the valve replacement surgery and did fine.

That is courage to me. The parents who take chances for their children: get into boats to escape war. Search for treatments. Fight for their home, their children, their loved ones. It is both men and women, mothers and fathers, grandmothers and grandfathers, and people who have no blood relation to a child that they reach out to help. Adoption, volunteering in schools, supporting a student, supporting an organization that helps children grow and thrive.

For the A to Z challenge….and last year.

 

 

 

 

Wall

This is for photrablogger’s Mundane Monday #94.

And bravo for this blog: https://safarfiertze.wordpress.com/2017/01/30/all-that-we-share/

and the Danes: https://youtu.be/jD8tjhVO1Tc  .

My paternal grandfather arrived as an immigrant from England. My father’s mother’s father was an immigrant from Scotland. My maternal uncle traces our family back to the Mayflower: immigrants.

Vital signs II

Pain is not a vital sign anymore, as I described in yesterday’s post. I wrote this poem in 2006, about pain  being the fifth vital sign. I disagreed.

Vital signs II

Pain
Is now a vital sign
On a scale of 1:10
What is your pain?
The nurses document
Every shift

Why isn’t joy
a vital sign?

In the hospital
we do see joy

and pain

I want feeling cared for
to be a vital sign

My initial thought
is that it isn’t
because we can’t treat it

But that isn’t true

I have been brainwashed

We can’t treat it
with drugs

We measure pain
and are told to treat it
helpful pamphlets
sponsored by the pharmaceutical companies
have articles
from experts

Pain is under treated
by primary care
in the hospital
and there are all
these helpful medicines

I find
in my practice
that much of the pain
I see
cannot be treated
with narcotics
and responds better
to my ear

To have someone
really listen
and be curious
and be present
when the person
speaks

If feeling cared for
were a vital sign
imagine

Some people
I think
have almost never felt cared for
in their lives

They might say
I feel cared for 2 on a scale of 10

And what could the nurses do?

No pills to fix the problem

But perhaps
if that question
were followed by another

Is there anything we can do
to make you feel more cared for?

I wonder
if asking the question
is all we need

first draft 5/20/06

I took the photograph Friday afternoon from the beach: two fronts were meeting. What is that like in the sky? Do they fight or welcome each other?

Pain as a vital sign

A recent article in the Family Practice News says that a survey of 225 physicians reveals that 33% of them think that the opioid crisis in the US is caused by over prescribing opioids. 24% said aggressive patient drug seeking and 18% said it is due to drug dealers. How quickly things change.

In 1996 pain was declared the fifth vital sign, after temperature,  pulse (heart rate), respiration rate and blood pressure. I disagreed with it because it focused on pain, by telling the nurses in the hospital and the outpatient providers to always to ask about pain. I thought it would be better to focus on level of comfort than pain. I thought we were using opioids far too freely and I thought that patients were getting addicted. The pain specialists said that we had to treat pain, and we were given very few tools other than opioids. Primary care providers were told that they could be sued for too much or too little pain medicine.

I also disagreed with it because pain is NOT a vital sign. That is, the level of pain does not correlate with illness. If a person has a high fever of 104 I am sure they are sick, a fast or very slow heart rate, a blood pressure too high or two low, they are breathing too fast: these are vital signs. They often correlate to illness and help us decide if this is outpatient, urgent or emergent. But pain does not. A chronic pain patient may have a pain level of 8/10 and yet not be an emergency or in a life-threatening state at all. That does not mean that they are lying or that we don’t wish to help with pain.

In June, 2016, the American Medical Association recommended dropping pain as a vital sign. https://www.painnewsnetwork.org/stories/2016/6/16/ama-drops-pain-as-vital-sign. The Joint Commission for Hospital Accreditation dropped pain as a vital sign in August, 2016. https://www.jointcommission.org/joint_commission_statement_on_pain_management/

Why? Not only were people getting addicted to opiates, but they were and are dying of unintentional overdoses: sedation from opiates with alcohol, with anxiety medicines such as benzodiazepines, with soma, with sleep medicines such as ambien and zolpidem. If the person is sedated enough, they stop breathing and die. The CDC declared an epidemic of unintentional overdoses in 2012: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm and said that more US citizens were dying of prescription medicines taken as instructed then from motor vehicle accidents and guns and illegal drugs.

So the poem below and a second poem I will post tomorrow reflect how I thought about pain as a vital sign. It is not a vital sign, because a high pain level does not tell me if the person is critically ill and may die. It does not correlate. Pain matters and we want to treat it, but the first responsibility is “do not harm”. Letting people get addicted and killing some is harm.

Also, opioids have limited effectiveness and high risk for chronic pain. I have worked with  The University of Washington Pain and Addiction Clinic since 2010 via telemedicine. They say that average improvement of chronic pain with opioids is about 30%. Higher and higher doses do not help and increase the risk of overdose and death. And the risk of addiction.

I think of pain as information. Studies of fibromyalgia patients with functional MRI of the brain show that they are not lying about their pain. In a study normal and fibromyalgia patients were given the same pain stimulus on the hand. The normal patients said that they felt 3-4/10 pain. The fibromyalgia patients felt 7-8/10 pain with the same stimulus and the pain centers lit up correspondingly more in their brains. So they are not lying.

Why would opioids only lower chronic pain about 30% even with higher doses? The brain considers pain important information. We need to snatch our finger away from a flame, stop if we smash our toe, deal with a broken bone. I think of opioids like noise cancelling headphones. Say you are listening to music. You put on headphones/take round the clock opioids. Your brain automatically turns up the gain: the music volume or the pain sensors. Now it hurts again. You take more. The brain turns up the gain. Now: take the noise cancelling headphones off. The music/pain is too loud and it hurts! With music we can turn it down, but the brain cannot adjust the gain for pain quickly.

We do not understand the shift from acute pain to chronic pain, yet. The shift is in the brain. I think that we are too quick to mask and block pain rather than use the information. Now the recommendations for opioids are to only use them for 3-5 days for acute pain and injury. For years I have said with any opioid prescription: try not to take them around the clock and try to decrease the use as soon as possible. Some people get addicted. Be careful.

If we don’t hand people a pill for pain, what can we do? There are more and more therapies. Jon Kabot Zinn’s 30 years of studying mindfulness meditation is very important. His chronic pain classes reduce pain by an average of 50%: better than opiates. Pain and stress hormones drop by 50% in a study of a one hour massage. Massage, physical therapy, chiropracty and acupuncture: different people respond to different modalities. Above all, reassuring people that the level of pain in chronic pain does not correlate to the level of illness or ongoing damage. And pain is composed of at least three parts: the sharp nocioceptive pain, nerve pain (neuropathic) and emotional pain. We must address the emotional part too. We have no tool at this time to sort the pain into the three categories. My rule is that I always address all three. That does not mean every person needs a counselor or psychiatrist. It means that we must have time to discuss stress and discuss life events and check in about coping.

In the survey of 225 providers, 50% estimated that they prescribe opioids to fewer than 10% of their patients. 38% said less than half. 12% estimated that they prescribe opioids to more than half their patients. The survey included US primary care, emergency department and pain management physicians.

Handing people a pill is quicker. But we can do better and primary care must have the time to really help people with pain.

Vital Signs I

In the hospital now
I am told we have a new
Vital sign
Like blood pressure and pulse
We are to measure
Pain
And always treat it

Sometimes I wonder

Mr. X is in the ICU
I tell his family
He may die

On a scale of one to ten
What is his wife’s pain?
His daughter’s
We are not treating them
Only Mr. X

We try to suppress pain
Signals from our nerves
Physical pain is easier

I think of our great forests
We suppressed fire

And that was wrong
If fire is suppressed
Undergrowth builds up
Fuel levels rise
Fire comes
Rages out of control
All is destroyed

If fires burn
More naturally
More regularly
What is left?

At first it looks desolate
The tall trees are burnt
Around their bases
But they live
Adapted to the fire
Majestic pines
Revealed
Would our values were as clear

Some pines
Seeds
Pinecones
Will only germinate
In fire
When the undergrowth
Is cleared
Conditions are right
For new growth

Perhaps pain is our fire
Grief is our fire

If we block pain
Where does it go?
Does the fuel build?

I wonder if the tall pines
Fear fire
Would they avoid it
If they could

Perhaps suppression
Is not the answer

Perhaps we can change
Remain present
Acknowledge pain
As normal
As joy

Perhaps if I
Step into the fire
I can remain
Present
For you

And you will be
Less alone
Less afraid

I open my doors

Let the fire burn

poem written before 2009

CDC guidelines for treating chronic pain: https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf

Who is driving the car?

I am at my parent’s house.

My mother and I and the baby, a toddler, go out to the car which is a huge newish SUV. I open the back door and see a drawing lying on the seat, beside the car seat. It is a drawing of my son, from a photograph. My mother has written on it, her ideas about how she wants to do the painting. I took the photograph and know it: my son has an exuberant joyous toddler expression. I climb in to the SUV. My mother gets in the front and turns the car on. She pulls forward and I start screaming, “STOP! STOP DON’T DRIVE! THE BABY IS NOT IN THE CAR!” My mother is pulling forward and backing, in confusion. She stops.

I leap out and search. Under the car by the back wheel, but not under it, is a kitten. A black kitten, lying on its side. I reach and very gently pick it up, supporting its spine. I am crying. The kitten cries as I pick it up, with pain. I say, “She’s hurt! I am going to die!”

I wake up.

I think about the dream. Even though there is a picture of my son in the car, I am a teen in the dream. The toddler is not my son. The toddler is not my daughter. The toddler is my sister. My parents had old cars, never a new SUV. The house in the dream was my parent’s house in Alexandria, Virginia. We moved there when I started ninth grade and my sister started sixth. My parents sold the house and moved in 1996.

Who is driving the SUV? Is there a responsible adult? Are they taking care of the children? Or are they driving recklessly and leaving the children to try to care for each other? Some adults are not responsible and should not be driving.

 

My son took the photograph of my daughter in 2011 for a school project, recreating a movie poster: True Grit.

the unwashed masses

I don’t have any of THEM as patients. The unwashed masses. All of my patients are smart.

There aren’t any unwashed masses.

I have a gentleman who is overweight, obese, diabetes. He is not stupid. He is not unwashed. He is not exercising or controlling his blood sugar right now because the temperature is below freezing. He has a hole in his trailer floor and no heat. So he huddles under the electric blanket.

I have a gentlewoman, also diabetic. She too is not stupid. She is not unwashed. She lost her husband to cancer and then everything else and then was homeless for a period. She has a small house but she has no heat. She stays in bed to stay warm. Her contractor quit before he put in the furnace and he’s gone bankrupt. She is cold.

I have veterans. They are not stupid. They are not unwashed. One was homeless for a long period and pooled his resources with another to rent a section 8 house. I am so proud of them. They are having trouble living together, each would rather live alone. Only sometimes they would rather not be alone. It is hard.

I have a massage therapist. She started to train as a counselor. To be a counselor, she needs a certain number of supervised hours and was getting this through the county mental health. “I didn’t know.” she says. “It is taking twice as long as I thought because half the time they don’t show up. They don’t show up because they don’t have gas, they don’t have food, they have been evicted, their son is in jail, they are in jail. I had no idea. My massage clientele is so different, they pay. I thought poverty was in third world countries, but it is here, in my county. I didn’t know.”

I know the people who live in the woods. A schizophrenic who comes once a month for his shot. He was losing weight. “Why are you losing weight?” I demand. “I am only eating once a day.” he says. I nag him to go to the community meals. He is shy, he is afraid of people and he is hungry. He is not stupid. He is not unwashed.

I have opiate addicts. Six years ago one expressed concern. He is 6 foot 5 and big. “I am afraid of some of the other people. You shouldn’t be doing this! It’s too scary and dangerous!” My opiate addicts are not stupid. My opiate addicts are not unwashed. Sometimes they relapse. Sometimes they die, in their 50s, 40s, 30s, 20s.

One in six people in the US is below the poverty level. They are not stupid. They are not unwashed.

And when someone talks about the masses, the people, the stupid people, most people are stupid, the sheep….

….I am beyond angry….

….my heart hurts….

Poverty in the US: http://www.census.gov/newsroom/press-releases/2016/cb16-tps153.html.

More: http://www.census.gov/topics/income-poverty/poverty.html.

The examples are taken from 25 years of practice, details changed for hipaa, but I can list dozens at any one time. The photograph is during the sunset after clinic, when I walked down town, the view across the sound.

 

birth

Reading about drugs

LSD
and that people re-experience the terrible trauma of birth

but wait: terrible trauma…

I had the grace and delight and sometimes terror
of catching babies, new and slippery and surprised
for nineteen years

they do not arrive traumatized

an older obstetrician
always gentle
when I would ask for help
deep calm and sometimes
he would wait for the newborn
and not rush us to the operating room

and if the child emerged
he would say “girl ears”
or “boy ears”
he always guessed
frequently wrong
his small tickle of humor
and the mother too busy at that moment
to notice at all
except that his voice was calm

I think of the one forming
in the womb
the sounds of mother’s heart and guts
dark and sounds
of father brother sister other

the first time I see
the new baby in clinic
I imitate the sound of the doppler
swish swish swish
and the newborn alerts, and knows my voice too

I think of the one forming
in the womb
and my daughter
who tried to come early
confining me to bed for three months
and adrenaline-like terbutaline
continuously
my hands tremble
my heart rate at one hundred
I knit to channel the figdets
six sweaters
and my daughter is worth it

I think of the one forming
in the womb
out of room
the space is too tight
can no longer stretch or kick
head down
ready

I think of the one forming
in the womb
saying now
I need more room
now and the cascade starts

we don’t know what starts labor
the baby or the mother
or both

now
I need more room
and the infant pushes towards the door
towards more room

and I have had
the grace and delight and sometimes terror
of catching them
slick and messy and bloody
as they emerge
into the light

open their eyes
and breathe
startled
at light and room and air