For the Ragtag Daily Prompt: vital. For me, vital brings up vital signs. I wrote this poem in 2006. Pain was made the fifth vital sign in 1996. I have written about it here. In June of 2016, the American Medical Association recommended dropping pain as a vital sign. The idea that we should be “free” of pain has not died yet and the latest CDC report says that the overdose death rate for women has risen a horrifying 240% from 1999 to 2017. That report is here: Drug Overdose Deaths Among Women Aged 30–64 Years — United States, 1999–2017. My poem is still relevant and we still have to change our ideas about pain.
Vital signs II
Is now a vital sign
On a scale of 1:10
What is your pain?
The nurses document
Why isn’t joy
a vital sign?
In the hospital
we do see joy
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
We measure pain
and are told to treat it
sponsored by the pharmaceutical companies
Pain is under treated
by primary care
in the hospital
and there are all
these helpful medicines
in my practice
that much of the pain
cannot be treated
and responds better
to my ear
To have someone
and be curious
and be present
when the person
If feeling cared for
were a vital sign
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
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
I took the photograph yesterday with my cell phone. It was so gloriously sunny that the water really was turquoise and I did no photoshop changes.
For the Ragtag Daily Prompt: slapdash. I can’t think of a photograph of something I want to call slapdash. It feels judgemental today, unless it’s something of mine, and that feels vulnerable. And then I start thinking about the sky…..
For mindlovemisery’s prompt: opposing forces. The prompts are admit/deny and presence/absence.
The pairs bring up my current sadness right away. I am struggling with the realization that we have a pervasive legal substance that works at the opiate receptor, is all over the US, and I have to send out urine tests for ALL of my chronic pain and opiate overuse and anyone on any controlled substance. You say, “but it’s legal”. I say, “Overdose and death risk. I can’t ignore it.” Here is the resulting poem.
admit to yourself you deny your addiction
the presence of the drug means the absence of the one I love
My town is a forest at sunrise and sunset. The trees take over, dark against the sky. And look, something is rising from the mist.
Medicine is like that too. Did the epidemic of unintentional overdose deaths catch you by surprise? People, including doctors, thought opioids were safe, if taken correctly. And that we should increase them if the person still had chronic pain. But the information is still changing and taking shape from the fog.
I have worked with the University of Washington Telepain service since 2011. I can’t attend every week, but many weeks I spend Wednesday lunch in front of the computer, logged on to hear a thirty minute lecture from UW and then to hear cases presented from all over the state.
I want to sing the praises of the doctors on Telepain and the Washington State Legislature for having this program. Here is a link to a five minute King5 news program about UW Telepain.
Forty two different sites were logged on. There are also UW Telemedicine programs for hepatitis C and for patients with addiction and psychiatric problems. The advantage is that all of we rural doctors learn from one doctor presenting a patient and the panel discussing it and making recommendations. We have Dr. Tauben, head of the pain clinic, a psychiatrist, a physiatrist, a family doctor who treats opioid addiction, a psychologist and a social worker. And often a guest speaker! We have a standard form to fill out, with no names: year of birth and male or female. It is a team that can help us to care for our patients.
New information in healthcare rises out of the mist….
Blogging from A to Z, my theme is happy things. Letter H is for HIPAA and health insurance and health information.
H is for hipaa: the Health Information Portability and Accountability Act, from 1996. I’ve been thinking about HIPAA and I have a question: if the patient handouts are supposed to be written at the fifth grade reading level for patients, why doesn’t Congress have to write laws at the fifth grade reading level?
Ignorance of the law is no excuse, right? Everyone in the US is supposed to follow the laws. Have you read them? I am supposed to follow HIPAA, right? I am supposed to follow the Affordable Care Act, (also nicknamed ObamaCare). It is 3600 pages long. It is written by Congress and attorneys.
What about health insurance? Have you read your health insurance policy? It’s a contract. If multiple US citizens have difficulty reading, why isn’t health insurance written at a fifth grade level?
CMS too and triwest and medicaid. I do not have time as a physician to learn the language of their websites. I run my own small practice. It is infuriating to try to read, understand and follow medicare, medicaid and Veterans Choice rules and they change every year. We ask why health care costs so much, and then there are over 800 different insurance companies, each with multiple insurance plans, and more and more people are hired to try to navigate and understand the rules. It’s ridiculous. We need a single payer system so there is ONE set of rules. Everybody in, nobody out.
One of the faculty said, “Patients can’t understand that.”
I said, “Well, I’m supposed to follow that law and I am not an attorney. ”
My patients are all smart in something. Some of them can’t read well. I have had two recently that I recognized a reading issue in the clinic room when I gave them a survey tool to fill out. I promptly said, “Let’s do this together.” I read them the questions and the answers. They are not stupid, but I am not sure that their reading skills were up to the form.
I am not using the American Academy of Family Practice patient handouts much because I think they are too dumb. I use the Mayo Clinic much more. I direct patients to the CDC, to NIH, to the Mayo Clinic website. Sometimes my patients may not be able to read at that level, but I think everyone appreciates being treated with respect. I am also happy to go over and explain more about a topic. I also warn them that there are loads of crappy medical sites and pseudo scientific sites and misinformation on the internet. If they want to look something up, I want them on a decent site.
Now how are these happy things to think about? It makes me happy to question my own behavior and my own assumptions. It makes me wonder how our country can insist that medical information has to be at a fifth grade level but lets Congress write laws that I find nearly unreadable.
Now I am warning my patients that a federal law may go into effect in January 2019, about opioids, and that it will be different and override the state law. Change will keep coming.
The photograph is from the beach last night: brant. What would the flock think about our health insurance?
“Siqalo used to be the most promising child in our house … the last born. He got the best of everything. We took him to better schools than we did his younger sister and brother. He did well for the better half of high school.Then he met up with the wrong friends, and never even got to matric,” Fanele Ngcobo tells GroundUp about his son.
Siqalo is 22. He has been a whoonga user since 2015. By 10am, he has already smoked his second fix. Without the drug he struggles to function. Withdrawal effects – which people refer to as “arosta” – include stomach cramps, vomiting, and extreme anxiety.
Whoonga is a mixture of marijuana and heroin and rumoured to contain anti-retrovirals, detergents and even rat poison. Active addiction has spread in KwaZulu-Natal townships such as KwaMashu and iNanda. Hundreds of people now live in Durban’s ‘Whoonga Park’,
Siqalo was a keen soccer player, says his mother, Sizakele. Now his worn, black soccer shoes peek out from under the bed in his old room at home in iNanda, Durban.
“He always went for practice with his friends at the local playground. But after a while, soccer wasn’t the only thing he and his friends were playing with; he was also experimenting with dangerous drugs,” she says.
Siqalo lives in so-called Whoonga Park, under a bridge next to the Berea railway lines in Durban. The park has become a den for whoonga users. They have bright beach umbrellas to protect them from the heat and black plastic bags for shelter. The activities under the bridge are in plain view. People trade and smoke. In the afternoons and at night, many take to the city streets to hustle for food and the money they need to buy their fix.
“There are no beds here. Even if you can get a blanket or sheet to sleep in, it doesn’t last a week. The police will burn it,” says Siqalo. “So it’s easier just to use cardboard and plastic as it is easy to find in the streets. Although I miss home, I cannot go back home like this. I need to be clean. My family doesn’t trust me around the house and for good reason because I’ve stolen their money and appliances too many times. I tried to be clean when they first fetched me, but arosta is too painful – nobody can understand. But I still want to go home.”
Cooked meals, showers and clean clothes
Nobuhle Khuzwayo from eMpangeni, KwaZulu-Natal, is one of those trying to get off whoonga. She attends the iSiphephelo Centre housed at the Denis Hurley Centre in Durban, where she gets cooked meals and clean clothes three times a week. For a few hours she is free of whoonga.
Co-founder of the centre Sihle Ndima says it is a place of safety for young girls and women living on the streets of Durban. It offers meals, counselling, clean clothes and showers.
“Many of them return back to the streets soon after classes, and the work we do seems like failure, because in the end they go back to using whoonga,” says Ndima. “We work with a rehabilitation centre in Newlands East, Durban, and they offer free help.”
Khuzwayo, who is 30, came to Durban seeking a job in 2014, but after numerous failed attempts, she was left homeless and desperate.
“The shoe factory I was working for closed down after a month. Thereafter it was difficult to get employment. I had been staying at the Dalton hostel with some friends, who later introduced me to smoking. They would tell me it was marijuana, but after becoming a frequent smoker … I would get headaches, pains and stomach cramps when I hadn’t smoked. I just could not cope without it. When I confronted them, they told me it was in fact whoonga. I was already deeply hooked,” says Khuzwayo.
She could no longer live at the hostel. She moved to Whoonga Park. To get money she would have to resort to sex work, crime or selling cigarettes. She found a boyfriend who sold cigarettes at taxi ranks to help get them food and the R30 a day they needed to buy whoonga.
“To survive on the streets, I got myself a boyfriend because you can’t survive a day alone under the bridge as a woman. There are men known as amaBhariya, who claim to own the spots in Whoonga Park. They do not smoke or deal the drug; they do not speak local languages or even English. They are ruthless. They rape and kill women under the bridge and make sure the park functions the way it does. They wear blue workmen’s clothes and hats and use the underground drains to move around. So if you don’t have a man to protect you, they will always take advantage of you,” says Khuzwayo.
Merchants outside the park sell whoonga for R30. “They are usually in the streets or in nearby flats but not many sell whoonga under the bridge,” she says.
Khuzwayo has now moved to a local shelter, paying R20 a night. Her closest friend had TB and when she died it was a turning point.
“I am tired of this life. I am determined to change. I don’t want to die a senseless death without dignity,” she says.
She is now a part-time cleaner at iSiphephelo. After attending all counselling and life skills classes she will qualify for rehab. “After rehab, I am going to go back home and stay with my sister in eMpangeni. You cannot stay away from whoonga in the city,” says Khuzwayo.
Siqalo and Khuzwayo say whoonga users are known as amaPhara. “Because we look like zombies. We’re dead people walking. We sleep standing. We stab you for your phone and sell it for a fix. Plastic and rubble is our shelter, faeces and rubbish are everywhere, and we run from police who destroy our things and chase us away every week. But we always come back. We can’t survive anywhere else,” says Siqalo.
Khuzwayo says she has seen people high on whoonga killed by trains.
“You can’t save them, because it’s like the railway shocks you, and you’re unable to move … seeing the train come at you but unable to run. I’ve seen some getting crushed in half and some losing their limbs. Even a security guard, who was chasing us one time, got stuck and the train crushed his foot.”
“One way or the other, you’re lucky to survive under the bridge.”
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