Mnemosyne

I am reading The Female Trickster: The mask that reveals, by Ricki Stefamie Tannen.

Regarding Mnemosyne, she writes: “The power of memory was recognized in Ancient Greece by the goddess Mnemosyne who ruled over the Elysian Fields. The nine daughters of Mnemosyne and Zeus are the muses, with Thalia, the muse of comedy imaged with a Trickster’s mask as she playfully composed comedy and ironic poetry. The muses were women unto themselves. According to the myth, upon death a person makes a choice to either drink from the river Lethe or the spring of memory. If you drink from Lethe you forget your pain and all the lessons of your life and are reborn again on earth. Those who choose to drink from the spring of memory go to the Elysian Fields, where there is no strife or pain. The myth tells us that the path to psychological integration comes from a willingness to value and interact with memory. Those that repress memory are doomed to repeat it, over and over again.” (pp72-73)

This seems apropos both to my personal and professional life and also to US culture. Our President speaks like my stage IV substance abuse patients. He says things that are obviously lies, obviously not true, obviously refutable and yet to all appearances he believes his own lies entirely, even when he contradicts himself. He manufactures his own reality and just laughs when someone else disagrees. But my substance abuse patients crash: they eventually find that they are isolated with their own lies when they become so fantastic and bizarre that no one believes them any more. We are watching that play out.

Re my personal life, I think of my maternal aunt’s memorial. I wrote two memories for the memory book. One was about my father saying that she had perfect pitch. I did not know what perfect pitch was when I was little, but I knew from my father’s voice, the respect, that it was special and important. That he was envious. That he admired it. The second was about my aunt and uncle’s divorce, that I had seen them as a unit and liked both of them better when they turned into individuals.

My cousins wanted to use the first memory but not the second. They said that family wouldn’t like it. I thought about their request and finally said no. Use both or neither. They chose neither. And this pretty much illustrates why I have very little contact from a large part of my family. I want to remember the whole person, light and dark, love them all. And that is not what that part of my family wants. An old family friend has not spoken to me about my sister since my sister died 6 years ago. I asked her directly about it a few months ago. She wants to talk to me “only about happy memories of your mother, father and sister.” I respond, “Why don’t you ask me what sort of relationship I want?”

She was and is silent. So I am too.

It’s not a lack of love but it’s a difference in philosophy. I think it is crazy to whitewash the dead: how will our children understand their own dark feelings and impulses and mistakes if they think that their ancestors, grandparents, parents are angels? Why aren’t we honest as a culture? How can we expect our children to be honest with us when we lie to them? The curated lives on Facebook are an abomination, false, lies and look what we have in the White House.

I like the dark as well as the light. If we truly love everything in the universe, how can we not love the dark as well as the light? If each of us owned our dark sides, our dark impulses, the myth says that we will not enact them over and over each generation. Owning the dark, acknowledging our own dark does not mean that we have to act it out in the world and then lie to ourselves and others.

And now I want coal for my stocking: just a small piece, to remind me that I have not always, or will I ever, only be good.

Mundane Monday #176: bones

For Mundane Monday #176: bones.

This is from the National Mississippi River Museum and Aquarium, in the Port of Debuque, Iowa. We had eight people in two vans, age range from 8 to 75, and drove there from Wisconsin. It was really excellent and something for everyone. A DiVinci exhibition, live alligators, this alligator snapping turtle skeleton, river boats and history.

What bones inspire you? The snapper was about four feet long, beak to tail, and the jaws and beak is very impressive. I’ve seen a pair of live ones in the wild on the outer banks of Virginia.

Link or message your Mundane Monday bone contribution and I will list them next week.

From Mundane Monday 175: line up:

KL Allendorfer finds lines in nature and …. frogs.

 

 

 

 

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.

Work place

Mostly I post photographs from outdoors, but this is clinic Friday afternoon. Mordecai took off her feather boa, wig and headdress and came into the exam room to add to a visual discussion about the sacroiliac joints. Mordecai is a plastic skeleton and her sacroiliac joints are attached incorrectly but conveniently for the sellers. After all, her bones don’t have the weight of a real skeleton nor does she have tendons or muscles or skin to connect everything. She is sitting beside my Netter Atlas of Human Anatomy, which I use in clinic every day. To show the knee ligaments and menisci, to show the back muscles, to show the connections of the psoas muscle….

Many thanks to Dr. Netter’s brilliant paintings and also to Mordecai for their help!

 

stomach flu

On call for my patients, I get a call about flu.

The spouse sounds worried. I speak to the sick person.

“Do you have a fever?”

“Yes, 100.6. I am throwing up and I don’t want to eat.”

“Do you have muscle aches?”

“Not really. I know I need to drink water.”

“Are you coughing?”

“Not really. Not much.”

“Not very congested. Do you have diarrhea?”

“Yes, lots. And my stomach hurts when I eat.”

People often say “flu” meaning “stomach flu” which is not influenza. “Stomach flu” is gastroenteritis, another set of viruses entirely. It could be a bacterial food poisoning, but in 17 years in my rural town, I have seen a total of two food poisoning bacterial infections. Most here are viral.

“Is there blood in the diarrhea?”

“No.”

Viral, then. Blood in the stool is more likely to be bacterial.

The important thing is to stay hydrated. If the person gets too dehydrated, they tend to just keep throwing up and may need iv fluids. To keep them out of the emergency room, I give the following recipe:

One quart of water
one teaspoon sugar
A pinch of salt
(with or without a pinch of baking soda)

If the person is quite nauseated, try drinking just a tablespoon every 15 minutes, with a timer. The electrolytes and sugar help the fluids absorb. Small amounts are easier to absorb and less likely to come up. If they keep throwing that up, go to the emergency room.

“I’m not eating.”

That’s ok. A day without eating won’t hurt you unless you are starting very underweight. Get the fluids in first and then you can go on to chicken soup and try some crackers.

Gatorade or flat ginger ale or pedialyte contain electrolytes too, but the home recipe is fine. And for small children, regular or pedialyte popsicles, because they can’t really drink them quickly.

Most people will recover on their own, especially if they stay hydrated. We don’t tend to try to stop the diarrhea, it’s better just to hydrate people to keep up. If someone is immunosupressed, on chemotherapy or with HIV or after a transplant, they may need hospitalization.

Does the picture look upside down? A bit nauseating or disorienting? I took it in Portland, and yes, it’s upside down.

Influenza and lung swelling

Influenza is different from a cold virus and different from bacterial pneumonia, because it can cause lung tissue swelling.

Think of the lungs as having a certain amount of air space. Now, think of the walls between the air spaces getting swollen and inflamed: the air space can be cut in half. What is the result?

When the air space is cut down, in half or more, the heart has to work harder. The person may be ok when they are sitting at rest, but when they get up to walk, they cannot take a deeper breath. Their heart rate will rise to make up the difference, to try to get enough oxygen from the decreased lung space to give to the active muscles.

For example, I saw a person last week who had been sick for 5 days. No fever. Her heart rate at rest was 111. Normal is 60 to 100. Her oxygen level was fine at rest. She had also dropped 9 pounds since I had seen her last and she couldn’t afford that. I sent her to the emergency room and she was admitted, with influenza A.

I have seen more people since and taken two off work. Why? Their heart rate, the number of beats in one minute, was under 100 and their oxygen level was fine. But when I had them walk up and down a short hall three times, their heart rates jumped: to 110, 120. I put them off from work, to return in a week. If they rest, the lung swelling will have a chance to go down. If they return to work and activity, it’s like running a marathon all day, heart rate of 120. The lungs won’t heal and they are liable to get a bacterial infection or another viral infection and be hospitalized or die.

I had influenza in the early 2000s. My resting heart rate went from the 60s to 100. When I returned to clinic after a week, I felt like I was dying. I put the pulse ox on my finger. My heart rate standing was 130! I had seen my physician in the hospital that morning and he grabbed a prescription pad and wrote: GO TO BED! He said I was too sick to work and he was right. I went home. It took two months for the swelling to go down and I worried for a while that it never would. I dropped 10 pounds the first week I was sick and it stayed down for six months.

Since the problem in influenza is tissue swelling, albuterol doesn’t work. Albuterol relaxes bronchospasm, lung muscle spasms. Cough medicine doesn’t work either: there is not fluid to cough up. The lungs are like road rash, bruised, swollen, air spaces smaller. Steroids and prednisone don’t work. Antiviral flu medicine helps if you get it within the first 72 hours!

You can check your pulse at home. Count the number of beats in one minute. That is your heart rate. Then get up and walk until you are a little short of breath (or a lot) or your heart is going fast. Then count the rate again. If your heart rate is jumping 20-30 beats faster per minute or if it’s over 100, you need to rest until it is better. Hopefully it will only be a week, and not two months like me!

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