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.

 

Red rock

Two days ago I went on a bike ride near the C & O Canal and we walked to this old stone cutting mill. Rocks were cut at the Seneca Quarry and and down the canal, which ends in Georgetown, and used for many buildings and monuments. Seneca Red Sandstone is used for the Smithsonian Castle. Beautiful.

This is for photrablogger’s Mundane Monday #75. He has sand and this is sandstone.

 

does chronic pain kill you?

Another writer sent me this story, saying that chronic pain killed Prince, not an overdose.

http://www.rawstory.com/2016/05/prince-did-not-die-from-pain-pills-he-died-from-chronic-pain/

My response is complex.

1. Is chronic pain an “illness” in it’s own right?

My answer is yes and no. It’s complicated and our understanding is evolving. Right now I think of chronic pain as a switch in the brain that gets thrown. It can be thrown by adverse childhood experiences, by infection, by trauma or war or abuse, by too much stress… or a combination of any of these.

2. Why a switch in the brain?

In fibromyalgia patients we can’t find much on physical exam, except that the pain seems out of proportion to the exam. Ditto with chronic fatigue, reflex sympathetic dystrophy, TMJ, etc. However, now we can image the brain with a functional MRI and watch which parts are lighting up and how much. A study of “normal” and fibromyalgia patients involved a standardized pain stimulus: a thumbscrew. (Kinky, right?) The normal patients said the pain stimulus was 3-4 out of 10 and their brains lit up a certain amount. The fibromyalgia patients said the same pain stimulus was 7-8 out of 10 and the pain parts of the brain lit up MORE corresponding to their pain level. So they are not lying… and it IS in their heads. Sort of. We aren’t sure whether the muscle is yelling more than normal or whether the brain is hypersensitive or both. My guess would be both.

And I think this is an adaptation. It is to get us to rest, heal, calm down, introspect, stop being type A, etc. Boy, do we suck at it. Though recently I had a person in clinic who said what their body wanted to do was nothing. They just wanted to lie around. I said, well, ok, so when can you do that? They did, for two weeks, at the holidays. And my patient said, “One day I had a cup of tea and a book and the cat on my lap and the dog at my feet. I realized that my adrenaline system was turning off and I felt calm and relaxed. Healed.” Back at work the person cannot always maintain it but is getting better at it.

3. What does this have to do with Prince?

The problem is that for 20 years we treated chronic pain with opiates. Unfortunately on continuous opiates, the brain cells change in many people and “down-regulate” the opiate receptors. Less receptors, the pain rises. The person needs more opiate. The brain removes more receptors. So two myths: one that if you have chronic pain and take medicine as directed, you can’t get addicted. Only dependent. Since that is a myth, the DSM-V has combined addiction and dependence into one diagnosis: opioid overuse syndrome. It is a spectrum, not two separate responses.

The second myth is that if you give enough opioid, it will help the pain. Well, no. UW Pain and Addiction Clinic says that on average pain is reduced about 30% by opiods, whatever the dose. And high doses start causing some weird  hyperalgesias. I’ve weaned two people from over 100mg methadone daily down to 20-30mg. It took two years. They felt better on the lower dose after they got through withdrawal symptoms and a short term increase in the pain receptors complaining at them. And they are much less likely to overdose and die.

Page two here http://www.supportprop.org/wp-content/uploads/2014/01/PROP_OpioidPrescribing.pdf discusses current knowledge about opioids.

4. So like, Prince?

He may have died from a combination of fatigue and sedating drugs. If you get enough sedating drugs, then you stop breathing. Opioids are the biggest offenders combined with alcohol or sleep medicine like ambien or benzodiazepines like valium or ativan or alprazolam or muscle relaxants like methacarbomal or a combination of all of the above. I am a strict physician about urine drugs screens and I do the dip in clinic in front of the person. Way too often, the person does not tell me about the alprazolam or whatever until I am holding the dip over the cup…. and that’s when they tell me. They got it from the ER or a friend or two years ago or … took their dog’s. Really.

He may have died from influenza, if he had it, with sedating drugs. Bad influenza causes lung tissue swelling and can mess up your oxygenation. Your heart has to take up the slack and go faster. If you are trying to work and your heart rate is well above normal, it’s exhausting. It can kill you.

He may have died from overwork, another infection, sedating medicines…. but not directly from chronic pain. Chronic pain slows us but I do not think it kills us*. What kills us is trying to treat it with a pill instead of resting and doing gentle exercise and saying: What does my body want?

 

5. Overdose?

Also, are we talking about an accidental overdose? Are we talking about drug abuse? Are we talking about accidental death or suicide or do we as a society think that addiction deserves overdose death but a person taking medicine for chronic pain is a tragedy? Aren’t we a bit judgemental?

Prince may have taken a pain pill as directed but taken it with too many other controlled substances or with alcohol or while sick and exhausted. Overdose means too high a dose. If it was two percocets, alcohol, flu and xanax…. it could be an accidental poisoning.

6. Are you sure?

No. Medicine changes. Our understanding of the brain changes. Science is about change and deepening understanding. We are barely getting started on the brain and I would say that we are in preschool there.

 

 

*Stress alone can cause heart attacks and sudden death:    http://www.health.harvard.edu/blog/stress-cardiomyopathy-a-different-kind-of-heart-attack-201509038239

The photograph is from a week ago, part of my Maxfield Parish cloud series, zoomed way in to the mountains across the water.

 

Advice to young people

My biggest piece of advice to young singles and young couples is: put half of each take home salary away. Married or not married, and I don’t care how committed you are.

I know people who lose their house when one half of a couple is sick, and the other can’t pay all the bills on one salary. We don’t want to think about illness or cancer, but it happens. Young parents, with one very ill and the other with a job, children and a sick spouse. Having a reserve is way more important than keeping up with the Joneses, unless you happen to inherit like Mr. Trump.

If you each put half of your take home salary away, then when life throws surprises at you, you will have a reserve. A big reserve if the surprises hold off for a while. Divide that half into retirement and half into money that you have access to in emergencies.

I listed the top ten causes of death in the US in 2012 here, but lets look by age: http://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2012-a.pdf.

From age 1 to 44 the top cause of death is accidents, unintentional injuries.

Suicide is second from age 15 to 44.

Cancer takes over as number one, malignant neoplasms, at age 45 to 65.

After 65, the number one cause of death is the heart, and that is where the biggest numbers are. But if a younger cause of death affects your family, it feels unfair, wrong, as if we all expect to like to age 78 or beyond.

Untintentional injury, that is, accidents, are broken down here: http://www.cdc.gov/injury. When I do physicals on teens, I ask them what the number one cause of death is for teens. They all know the answer, even if they have to think for a moment: motor vehicle accidents.

But lets look at accidents in the age 25-65 age group: poisonings. What? Poisoning? And NOT intentional…. what is going on there? It is drugs, legal and illegal, but more legal. Sedating drugs in combination are effective at sedating people enough to stop breathing and die. Alcohol with benzodiazepines (valium, ativan, etc.), opiates and opioids, sleep medicines such as ambien and sonata, withdrawal from methamphetamines, cocaine, crack….people die. And supplements may be contributing as well.

75 years of US mortality data: http://www.cdc.gov/nchs/data/databriefs/db88.pdf#x2013;2010%20

At birth now in the US the life expectancy averages 78, but not everyone reaches that….some people still die younger and some live longer.

The age of death is rising, world wide. In the US, many of us have a world envied standard of living and yet we have a significant number of people who are anxious and depressed and way too high a rate of substance abuse, alcohol, opiates and opioids, benzodiazepines and yes, marijuana is addictive. How do I reconcile this? How do you reconcile this?

Keep your reserve, young singles and young couples…..

http://www.worldlifeexpectancy.com/usa-cause-of-death-by-age-and-gender
As of the day I am writing this on 5/2/16:

POPULATION
318,857,056

Numbers to be corrected, first set was wrong, wrong, wrong.

I took the photograph yesterday evening: there were the most amazing Maxfield Parish clouds…. life and death are a mystery.

practical medicine

This week I see a patient that I sent to a specialist that I don’t know well.

“How is he?” I like to get feedback on the specialists.

Q grimaces. “He knows his stuff. But…. he’s by the book. I complained about a side effect. He says it is not listed. But I go on line and there are lots of people complaining about that side effect.”

“Hmmm.” I say.

“He doesn’t really listen if it doesn’t fit…. if it’s not in the book.” Q brightens. “But I am going to call the nurse line for the drug and see what they say.”

“Cool.” I say. “Some doctors are very by the book. I’m into practical medicine: use it if it works. Don’t care if it’s witchcraft.”

Q giggles.

“What about the rash?” I say.

Q pulls up a pant leg. There is almost no rash. “He said it wasn’t related to the problem.”

We both look at Q’s leg. “Looks better to me.” I say. “Looks a lot better.”

“Yeah,” says Q. “It does. It looks nearly gone.” The rash was what initially triggered the testing that led to the diagnosis that led to the specialist.

“I use whatever I can figure out for people.”

Once I had an elderly woman with an intestinal bleed. She is transferred to Virginia Mason and goes through every possible test to localize the bleed. Upper endoscopy, lower endoscopy, swallow the camera, CT scan, probably pet scan and bone scan. Can’t find it. It is too slow a leak to use radioactive tagged red blood cells. She comes back.

I transfuse her every three weeks. This is not good. She will develop antibodies eventually.

She goes back to Virginia Mason. They do it all again. The surgeons discuss opening her up. “No.” they say. “Too frail at 88. She will die on the vent.” They send her back.

I am still transfusing her every three weeks. I am grumpy as hell.

Her daughter says, “I have a friend in Canada who knows a scientist. He is studying aloe vera. They said take aloe vera twice a day. What do you think?”

“Well I don’t have anything! Try it! We will test a chem panel in two weeks and watch the blood count!”

She takes aloe vera twice a day. Her blood count stabilizes. No more transfusion. Happy dance. Not absorbed or at least doesn’t bother her kidneys or liver tests….

After a year she says, “Can I try stopping it?”

“Sure,” I say. “We will check a blood count in 2 weeks.”

It drops. She goes back on aloe vera.

Practical medicine. If the book has nothing, try something else…..

Admitting diagnosis: Old guy, don’t know

During my three months temp job in 2010 at a nearby Army Hospital, I was asked to help the Family Medicine Inpatient Team (FMIT) whenever a faculty member was sick or out, which turned out to be fairly often. I enjoyed this because I wanted to work with residents, Family Practice doctors in training. It was very interesting to be at a training program, watch the other faculty and work at a 400 bed hospital instead of my usual 25 bed one.

Two patients needed to be admitted at the same time on our call day, so the second year resident took one and I took the other. The report on mine was an 82 year old male veteran, coughing for three weeks, emergency room diagnosis was pneumonia.

The resident soon caught up with me because her person was too sick and got diverted to the ICU. Mr. T, our gentleman, was a vague historian. He said that he always coughed since he quit smoking 15 years ago and he couldn’t really describe the problem. He’d gotten up at 4:30 to walk around the assisted living; that was normal for him because he used to do the maintenence. He had either felt bad then or after going back to sleep in a chair and waking at 10. “I didn’t feel good. I knew I shouldn’t drive.”

He’d had a heart attack in the past and heart bypass surgery. Records were vague. The radiologist read the chest xrays essentially as, “Looks just like the one 3 months ago but we can’t guarentee that there isn’t a pneumonia or something in there.” He had a slightly elevated white blood cell count, no fever, and by then I did a Mini-mental status exam. He scored 22 out of 30. That could mean right on the edge of moderate dementia, or it could be delerium. I got his permission to call his wife.

“Oh, his memory has been bad since he spent a year in a chair telling them not to amputate his toes. And he was on antibiotics the whole time. He wasn’t the same after that. He just said he didn’t feel right and that he shouldn’t drive.” So his wife called an ambulance.

The third year chief resident came by and wanted to know the admitting diagnosis. “Old guy, don’t know.” was my reply. “Either pneumonia or a urinary tract infection or a heart attack maybe with delerium or dementia or both.”

The second year was helping me put in the computer orders, because I was terrible at it still. She could put them in upside down and asleep. “Why are we admitting him, anyhow? We can’t really find anything wrong, why not just send him home?”

“We can’t send him home because he can’t tell us what’s wrong. He might have an infection but he might not, and he has a really bad heart. If we send him home and he has a heart attack tonight, we would feel really bad. And he might die.”

I was getting a cold. I had planned to ask to work a half day but half the team was out sick so I just worked. But by morning I had no voice and felt awful. I called in sick.

At noon the phone rang. It was the second year. “You know Mr. T, who we admitted last night?”

“Yes,” I said.

“He had that heart attack during the night. Got taken to the cath lab. You made me look really good.” We had worked on the assumption that it could be early in a heart attack though the first labs and the ECG were negative. I had insisted on cardiac monitoring and repeating the enzymes. The resident had finished the note after I left and the night team had gotten the second and abnormal set of enzymes.

82 year olds are tricky. With some memory loss he couldn’t tell us much except that “I don’t feel right.” He was right not to drive and we were right to keep him in the hospital. And if it had all been normal in the morning, I still would not have felt bad about it. The residents are looking for a definitive diagnosis, but sometimes it’s “Old guy, don’t know,” until you do know.

 

Previously posted on everything2.com in April 2010. I am not sure if this branch was dead or not, but the moss grows on it here in the wet winter anyhow.

I took the photograph in the woods last weekend.

Armour Suit IV: Walk like a toddler

At each massage, one every two weeks, I have locked my hips back up in the Armour suit. This is really annoying.

My massage person says he wants to be able to lie face down like a baby: head, arms and legs all lifted and playing. That is core strength. Babies can do that… why can’t we? He says that when he does play therapy with kids, by a certain age they lose that. He picks them up and flies them around lying on his arms: by age 4 or 5, they fold up. They have lost touch with that core.

I think about that.

During a massage a few months ago he pokes my lower belly. “Tilt your hips using your abdominal muscles.” Feels weird, but I do. “You aren’t engaging your core.” I find it really annoying to have to relearn how to walk.

Engaging my core. Little children who have just learned to walk do lead with their bellies. And they can still lie on the floor on their bellies, all limbs up.

I am trying to picture an adult who walks with their belly. Who? The Buddha’s belly comes to mind. But I can’t see him walking. Who? Toshiro Mifune: the old samurai movies. He and the others walk like small children: from their core, from their bellies.

I try it for two weeks. I flatten the arch of my lower back by using my abdominal muscles, not my gluteus maximus. I walk with my feet apart a bit, my belly leading. I am trying not to walk with my toes gripping the ground. I walk with toes up. He says I have walked with my toes gripping the ground for years, and that is the only place that I have early arthritis.

It feels a bit silly to walk like a samurai. When I do it right, I can feel that engaged core and my legs and hips feel looser. It is not elegant, not a catwalk uptight shake your ass walk. It is more of a loose free walk, like a toddler, like a buddha. I don’t care. I have to concentrate to keep my abdominal muscles flattening the arch of my back, and so I walk slower.

After two weeks I am back: it’s worked. Partially. My hips are LESS locked. The metatarsal phalangeal joints, the big toes, are less sore then they’ve been for years. And I can feel that abdominal core.

Skiing I try to do the same thing. Engage the abdomen and keep it engaged, and ski with my toes up. I ski slowly and with great swooping turns, letting the skis do the work. Rentals. They give me 158s the first day, I talk them into 165s the second day and then I am on 172s. Finally feels stable. I am getting used to that core feeling. I quit when I get too tired, going in before my kids.

Walk like a toddler, walk like a samurai, walk with core engaged.

First published on everything2.com January 7, 2016. I needed the right picture: this is my sister and me about a month before she died of breast cancer. I miss her so.