freedom

For the Ragtag Daily Prompt #76: freedom.

Immigrant children separated from parents and placed in “camps”. This is concentration camp, jail. They have not been returned to their parents: https://www.npr.org/2018/06/19/621065383/what-we-know-family-separation-and-zero-tolerance-at-the-border. This is a horror committed by my country. Return the children to their parents.

The deer were in the empty lot across the street from my clinic yesterday. Both fawns went to check in with their parent when I got out of the car with my camera. Imagine the terror of a small child whose parents have been taken away.

Stages of Grief: anger

I am thinking of the songs that comfort me in grief.

And thinking about the stages of grief. Five, right? Denial, Bargaining, Anger, Grief and Acceptance. My sister said, “They left out Revenge and Acting Out. ” She died of cancer in 2012 at age 49. Six days after her birthday and the day after mine.

Anger songs for grief. But denial is first, right? Not necessarily. These are not stages you move through in a certain order. This is more like a spiral, where you go from one to the next and back to the start, from day to day or even hour to hour.

I’ve already written about My Name is Samuel Hall. That is an angry song, unrepentant, that my sister wanted the last time that I visited her. I knew that she was furious about dying and leaving her husband and daughter. And me and her friends.

My mother sang:

“Nobody loves me, everybody hates me, I think I’ll go eat worms. Big fat slimy ones, little tiny wiggly ones, see them wiggle and squirm. Bite their heads off, suck their guts out, throw the skins away. I don’t see how anyone can live on three meals of worms a day… without dessert….”

She also taught us this:

“I don’t want to play in your back yard
I don’t like you any more
You’ll be sorry when you see me
Sliding down my cellar door”

My parents had songs for every mood I can imagine. There were moods they would not speak about but they sang them.

My favorite angry groups are The Devil Makes Three, Hank Williams III, The Offspring, and Sweet Honey in the Rock.

Sweet Honey in the Rock? Yes. They sing about death a lot. This song is not about death: it’s about a “bad” woman, wanted dead or alive. But listen to the song: they are singing about a real event and a woman who fought back against a rape. On the thirty year album of Sweet Honey in the Rock, the group says that their first “hit” was this song, played by news stations. “It was a hint that we were not going to be top 40.” The song is Joanne Little.

So here are three songs by the others:

The Offspring: Why don’t you get a job?

The Devil Makes Three: All Hail

Hank Williams III: My Drinking Problem

And how do families show anger? They fight. They fight with each other. They fight about how someone should die, what should be done about mom, whether dad can live alone any more, about the right way to grieve. They fight about small things or big things and they even sue each other. Before you wade into the fray, step back. Remember, families grieving are always a little bit insane, very stressed and it’s all grief.

Hank Williams III: Country heroes

Blessings on the people I know in hospice right now and on their families and loved ones. Third one today. Sending love.

 

 

 

The extroverted feeler and responsible behavior

My son is an extroverted feeler and my daughter is an introverted thinker.

When he was 12 and she was 7, their father and I were working out the details of a divorce. Their father moved out for a year, moved back in for a year, and now was out again. It had taken me two years of couple’s counseling to decide that yes, we did need to get divorced. Now we were in the year of hammering out the details.

One day he came over and was obnoxious and rude. I got angry and yelled and threw him out. I slammed the door after him. I didn’t usually do that and it felt both good and bad.

The kids were conferring. I wondered if I’d scared them, losing my temper. They both came to me.

“Mom, we don’t want you to yell at dad and make him leave.” said the EF, arms crossed. The IT stood beside him. “And no slamming doors.”

“But he was rude first!” I said, realizing as I said it, uh, lame. And where have I had this conversation before?

“We know that he was rude. But we aren’t talking about him. We are talking about your behavior. We don’t care what he does.” They both looked stern and fierce.

“So I have to behave no matter what he does.” I said. They nodded. “You are right. I apologize for yelling at dad, throwing him out and slamming the door. I need to behave anyhow. That’s what I tell you, right?”

“Yes, mom.” And then they both hugged me to comfort me.

I felt sheepish for behaving badly, but mostly proud. Proud that my kids felt comfortable confronting a misbehaving adult and the one with whom they were living, me. Right after a yelling tantrum, too. And proud that they were giving me back the message that I’d given them for years: I don’t care what the other kid did, that is not acceptable behavior. And overall I felt pretty good that I really had not yelled and slammed doors very often: we’d done the majority of our fighting in the counselor’s office and had tried to make it very clear that it was not the kids’ fault.

The photograph is of my son in Thailand. He was a Rotary Exchange Student, to Trang. I don’t know who took the photograph.

Previously published on everything2.com.

 

Long notes and unhappy patients.

A patient of mine saw a cardiologist recently.

His previous cardiologist has retired. The patient had a cardiac bypass in the past, he has a stent, he has known coronary heart disease and he’s in the young half of my practice. That is, under 60.

He had not seen a cardiologist for 2-3 years because he had a work injury, worked with Labor and Industries, the case was closed, he couldn’t go back to work, he found a lawyer. He lost his regular health insurance along with the job, so couldn’t see the cardiologist.

The L & I case is reopened. A physiatrist recommended specific treatment that was not done, and that allowed the case to reopen.

The specific treatment center then notes that he has heart disease and that he needs clearance from a cardiologist. I set him up with a new cardiologist.

“How was the visit?” I ask.

He shrugs. “The staff was nice.”

“I have the note.”

“The cardiologist spent under ten minutes with me. It was clear that she was rushed. She did not seem very interested. It was difficult to get my questions answered.”

“Her note is six pages.”

He snorts. “Great that she could get a six page note out of that visit.”

“Do you want a copy?”

“No.”

He is cleared for the specific treatment.

I have no doubt that the cardiologist spent more than 6-8 minutes on his visit and his note. But not in the room. Other people are entering the information filled out in the waiting room, medicines, allergies, past medical history, family history. Hopefully the cardiologist is reading my note and letter. But the problem is, doctors aren’t doing it in the room. So the impression left with the patient is that we spend 6-8 minutes on their visit, we are late, we are rushed. Doctors are looking at data. They are not listening to patients.

Medical Economics, a journal that arrives without me asking for it, says over and over that we need more physician “extenders”, that we need to have people doing the data entry, people doing the patient teaching, more people and machines….No. They are wrong. We need LESS barriers between us and the patients, not MORE. We need more time with patients. Every single extender we add burns physicians out more, because the salary has to be paid AND more patients seen faster to do that AND we are still ultimately responsible for knowing and reading and absorbing every single piece of information that is placed in that patient’s chart. An extender is NOT an extension of my brain and an extender is another person I have to communicate with and train.

Just. Say. No. to the managers who pile MORE barriers between the physician and the patient. NO.


It just makes me so mad that he lost his health insurance BECAUSE he got injured at work and so then his heart disease goes untreated as well… can’t afford medicines…if he then has a heart attack while uninsured we lifeflight him to Seattle, it costs a fortune, he loses his house and property and then is on medicaid and may end up on permanent disability, and what are the chances he returns to work? The US medical corporate money grubbing is insane. Single payer, medicare for all, make the US great again.

Make America sick again: diabetes

The trend in diabetes treatment is clear: keep Americans sick.

The guidelines say that as soon as we diagnose type II diabetes, we should start a medicine. Usually metformin.

A recent study says that teaching patients to use a glucometer and to check home blood sugars is useless. The key word here is teach, because when I get a diabetic transferring into my clinic, the vast majority have not been taught much of anything.

What is the goal for your blood sugar? They don’t know.

What is normal fasting? What is normal after you eat? What is the difference between checking in the morning and when should you check it after a meal? What is a carbohydrate? What is basic carbohydrate counting?

I think that the real problem is that the US medical system assumes that patients are stupid and doesn’t even attempt to teach them. And patients just give up.

New patient recently, diabetes diagnosed four years ago, on metformin for two years, and has no idea what the normal ranges of fasting and postprandial (after eating) are. Has never had a glucometer.

When I have a new type II diabetic, I call them. I schedule a visit.

At the visit I draw a diagram. Normal fasting glucose is 70-100. Borderline 110 to 125. Two measurements fasting over 125 means diabetes.

After eating: normal is 70-140. Borderline 140-200. Over 200 means diabetes.

Some researchers are calling Alzheimer’s “Type IV diabetes”. The evidence is saying that a glucose over 155 causes damage: to eyes, brain, kidneys, small vessels and peripheral nerves.

Ok, so: what is the goal? To have blood sugars mostly under 155. That isn’t rocket science. People understand that.

Next I talk about carbohydrates. Carbohydrates are any food that isn’t fat or protein. Carbohydrates range from simple sugars: glucose and fructose, to long chain complicated sugars. Whole fruits and vegetables have longer chain carbohydrates, are absorbed slowly, the body breaks them down slowly and the blood sugar rises more slowly. Eat green, yellow, orange vegetables. A big apple is 30 grams of carbohydrate, a small one is 15, more or less. A tablespoon of sugar is 15 grams too. A coke has 30 grams and a Starbuck’s 12 ounce mocha has 62. DO NOT DRINK SWEETENED DRINKS THEY ARE EVIL AND TOOLS OF THE DEVIL. The evidence is saying that the fake sugars cause diabetes too.

Meals: half the small plate should be green, yellow or orange vegetables. A deck of card size “white” food: grains, potatoes, pasta, whole wheat bread, a roll, whatever. A deck of card size protein. Beans and rice, yes, but not too much rice.

For most diabetics, they get 3 meals and 3 snacks a day. A meal can have up to 30 grams of carbohydrate and the snacks, 15 grams.

Next I tell them to get a glucometer. Check with their pharmacy first. The expensive part is the testing strips, so find the cheapest brand. We have a pharmacy that will give the person a glucometer and the strips for it are around 4 for a dollar. Many machines have strips that cost over a dollar each.

I set the patient up with the diabetic educator. The insurance will usually cover classes with the educator and the nutritionist but only in the first year after diagnosis. So don’t put it off.

For type II diabetes, the insurance will usually only cover once a day glucose testing. So alternate. Test 3 days fasting. Test 1-2 hours after a meal on the other days. Test after a meal that you think is “good”. Also after a meal that you think is “bad”. I have had long term diabetics come in and say gleefully “I found a dessert that I can eat!” The numbers are not always what people expect. And there are sneaky sources of carbohydrate. Coffeemate and the coffee flavorings, oooo, those are REALLY BAD.

For most of my patients, the motivated ones, they have played with the glucometer for at least a week by the time they see the diabetic educator. I have had a person whose glucose was at 350 in the glucose testing. The diabetic educator called and scolded me for not starting metformin yet. The diabetic educator called me again a week later. “The patient brought their blood sugars down!” she said. “She’s under 200 after eating now! Maybe she doesn’t need the metformin, not yet!” Ah, that is my thought. If we don’t give people information and a tool to track themselves, then why would they bother? They eat the dessert and figure that the medicine will fix it or they can always get more medicine.

Type I diabetes has to have insulin. If a type II diabetic is out of control, high sugars, for long enough, they too will need insulin. The cells in the pancreas that make insulin are killed by prolonged high blood sugars.

I went to a lunch conference, paid for by a pharmaceutical company, at the AAFP conference in September. The drug company said start people on metformin at diagnosis and if they are not in control in 3 months, start a second medicine, the drug company’s new and improved and better and beastly expensive medicine!!!

Yeah, I don’t think so. All of my patients are smart and they all can figure it out. Some get discouraged and some are already on insulin, but they are still all smart.

Fight back against the moronization of US citizens. Keep America healthy, wealthy and wise.