Category Archives: fight

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Practicing Conflict II

Practicing conflict II

In Practicing conflict, I wrote about practicing conflict by arguing different sides of a topic inside my head. I wrote that I don’t fear conflict and have learned to enjoy arguing with myself. I am a physician and physicians argue all the time.

What? No they don’t. Well, the doctor persona does not argue with the patient much. Some doctors give orders to patients, others try to negotiate, some try to convince. But behind the scenes, doctors are more like the Whacky Racer Car with the Cave Guys, running with their feet and hitting each other with clubs.

In residency in Family Practice at OHSU in Portland, Oregon, I start on General Surgery during internship. This is in the early 1990s and there was not much in the way of “disruptive physician” rules. I have to cover Trauma and Plastic Surgery and General Surgery at night on call. The resident is present but I get paged first for patients on the floor. I learn that I should go to all Trauma pages in the emergency room. If I know what is happening with the new Trauma patient, it’s a lot easier to handle the phone calls for more drugs and so forth. Also, the resident is less mean to me.

We attend the Trauma “Grand Rounds”. These are unreassuring to a new intern. A resident presents a trauma patient, giving the history in the accepted formal order. The Faculty Trauma Surgeons interrupt, disagree with management of the patient and yell. They yell at the resident and at each other. The upper level residents yell too, being well trained. The Trauma Surgeons do not agree with each other. They are inflammatory and rude. I am shocked initially: medicine is not a cookbook, is not simple and it appears that it is a controversial mess. It turns out that medicine IS a controversial mess.

There is not as much yelling on the next rotation. At that time Trauma Surgeons yelled more than any other set of doctors that I ran across. They yelled in the ER, at each other, at the staff, at the nurses, at the residents. The culture has changed, I suspect, but that’s how it was then.

I take Advanced Trauma Life Support as a third year resident. The Trauma Surgeons at OHSU helped write the course. They don’t agree with it. On some questions the teaching Surgeon says, “The answer to this question is (c), “ followed by muttering loudly, “though I totally don’t agree with that and I would do (b).” Another Trauma resident or surgeon then might start arguing with him, but they moved on pretty quickly, to teach the current agreed best practices in the book. Which change every few years. Great.

Years later (2009) I join the Mad as Hell Doctors, to go across the US talking about single payer. They are a group from Oregon. Physicians for a National Healthcare Program are a bit cautious with us the first year: we might be whackos. We have an RV with our logo and we have a small fleet of cars and what do you think we do in the cars? We argue. Or discuss. Or whatever you want to call it. We spend the driving dissecting issues and how to present things best and tearing apart the last presentation and rebuilding our ideas. The group does 36 presentations in 24 days. Each presentation takes an hour to set up, two hours to do and another hour to break down and debrief. We get more and more exhausted and cranky and um, well, argumentative, as the trip proceeds. Even though I think of the Whacky Racer Cave Guys running with their feet and bonking each other with clubs, this is the most wonderful group of doctors I have ever been with. A common goal that we all want to get to, discussing and disagreeing on strategy all the way! I feel closer to those physicians in a week then I feel to any of the physicians that I’ve worked with for the last 9 years in my small town. Conflict with a common goal.

Doctors are TRAINED to argue, even with themselves, to document every decision in the chart with reasons why they have reached that decision. And that they have thought about all of the reasons for say, a low potassium, thought of every possible cause and worked their way through testing. The testing always has two strands. One strand is rule out the things that could kill the person NOW, even if rare. The other strand is what is common? You have to think about both at the same time, always. And argue with yourself about which tests should be done, in what order, what is most important, how do you treat the person while awaiting results, and have I missed anything? And if we aren’t sure, we call another doctor, run it by them, wait for them to shoot holes in our logic or to say, no, I can’t think of anything else.

We can deal with conflict. We must deal with conflict. The world is too small not to deal with conflict, with disagreements, with different viewpoints and positions and ideas. If doctors can do it every single day at work, then everyone else can too. Trying to see all the positions and possible diagnoses saves lives in medicine. We need to extrapolate that to everything else. Try to see other positions, try to understand them, to respect them. We can and we must.

Blessings.

Here are the Whacky Racers:

And Madashell Doctors blog: http://madashelldoctors.com/category/uncategorized/page/3/

For the Ragtag Daily Prompt: discuss.

The photograph is from my clinic once we had stopped seeing patients and were selling everything. Mordechai was our clinic skeleton, made of plastic, from China. This was in January 2021.

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Practicing Conflict

An essay from my church talks about the writer avoiding conflict, fearing conflict and disliking conflict. This interests me, because I do not avoid conflict, I don’t fear conflict and actually, I like it. Our emeritus minister once did a sermon in which he said that when you are thinking about two conflicting things at once, that is grace. I have thought about his words many times, especially when I am not in agreement about something.

Does this interest in conflict mean I fight all the time? Well, sort of, but not in the way you think. I don’t fight with other people much. I fight myself.

What? No, really. Most topics have multiple sides. Not one, not two, but many. Like a dodecahedron or a cut gem. Hold it up to the light, twelve sides, each different. I argue the different sides with myself.

I learned this from my parents. My parents would disagree about something, they would discuss or argue about it, and then they would bet. Sometimes they bet a penny, sometimes a quarter, sometimes one million dollars. Then one of them would get up and get the Oxford English Dictionary, or the World Atlas, or some other reference and look it up. This was pre-internet, ok? 1970s and 1980s.

Sometimes my parents would even pay each other. The penny or quarter. My father spoke terrible French and my mother had lived in Paris for a year after high school, so he could get her going by insisting that his French was correct. It wasn’t. Ever.

There were other arguments in the middle of the night that were not friendly and involved yelling, but the daytime disagreements were funny and they would both laugh.

Once my sister is visiting after my mother has died. My father is present. My father, sister and I get in a three way disagreement about physics. I’m a physician, my sister was a Landscape Architect and my father was a mathematician/engineer, so we are all three talking through our hats. However, we happily argue our positions. Afterwards, my gentleman friend says, “That was weird.” “What?” I ask. “That was competitive and you were all arguing.” “It was a discussion and we disagreed.” “I won’t compete.” “We let my dad win, because it makes him happy.” “That was weird.” “Ok, whatever.”

My gentleman friend is also shocked when my teen son challenges me at dinner. My son says, “I am researching marijuana and driving for school and there isn’t much evidence that it impairs driving.”  I reply, “Well, there is not as easy a test as an alcohol test and it was illegal, so it has not been studied.” We were off and having a discussion.

Afterwards my gentleman friend says, “I am amazed by your son bringing that up. We weren’t allowed to discuss anything like that at dinner.” I say, “We pretty much discuss anything at dinner and both my kids are allowed to try to change my mind. About going to a party or whatever.” He shakes his head. “That is really different.” “Ok,” I say.

This habit of challenging authority, including adults, did not go over well when my son was an exchange student to Thailand. It did not occur to me to talk to him about it. He figured it out pretty quickly.

Back to my internal arguments. If I take a position, I almost immediately challenge it. I think of it as the old cartoons, with the angel on one shoulder and the devil on the other. The devil will make fun of things and suggest revenges and generally behave really badly. The angel will rouse and say, “Hey, you aren’t being nice.” Then they fight. The internal battle very quickly becomes comic with the two of them trading insults and bringing up past fights and fighting unfairly. When it makes me laugh inside, I can also be over the driver who cut me off, or someone who spoke nastily, or whatever. My devil is very very creative about suggested revenges. When the angel says, “You are meaner than the person who cut you off!” I am over it.

When I was little and disagreeing with my family, my sister could tell. “You have your stone face on!” That meant I was attempting to hide a feeling, especially fear or anger or grief. Siblings and family are the most difficult because they can read us and see through us like glass. My physician training also teaches control of feelings. I have sometimes wanted to grab a patient and scream “Why are you doing this to yourself?” but that really is not part of the doctor persona. I am doing it inside, but I can put it aside until later. Then the devil goes to town! And the angel tries to calm the devil down.

Maybe we all need more of this skill. Pick a mildly controversial topic. Argue one side of it. Then switch positions and argue the other side. Go back and forth until it gets ridiculous. Let each side get unreasonable and inflammatory and annoying. This can play in your head and not on your face. Once you can do a mild topic, move on to something a bit more difficult. If you only know the arguments on your side, read. You can find the other side, the internet is huge. Start gently.

A friend says, “You always argue about things.” I say, “I prefer to think of it as a discussion.” “You always take the other side.” “Well, it interests me. And if there is no one to discuss something with, I discuss it with myself!” “Weirdo,” says the friend. I think he’s jealous, really I do. Don’t you?

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Covid-19, Long Haul and the immune system

“Whether immune-mediated secondary OCD could also develop as a consequence of COVID-19 poses a highly relevant research question to be elucidated in the near future [35, 36]. The first studies of their kind have demonstrated infection-triggered neuronal antibody production against various antigens in COVID-19 patients who were presenting with unexplained neurological symptoms [37].” from https://www.nature.com/articles/s41398-021-01700-4

Um, yes. It is looking highly likely that chronic fatigue, fibromyalgia, and Long Haul Covid-19 are all immune system responses. They are not simple at all. They can involve antibodies, cytokines and killer T cells and probably other things.

Antibodies: the difficulty here is that we all make different antibodies. It’s all very well to say that people with PANDAS and PANS make antibodies to Dopamine 1 and 2 receptors, tubulin receptors and lysoganglioside receptors, but people each make different antibodies. The antibodies can attach and block the receptor or can attach to the receptor and turn the key: act like dopamine, for example. Dopamine makes people tachycardic, a fast heart rate. If dopamine receptors are blocked, that could be a source for “brain fog” and feeling down.

Cytokines: I worked at the National Institutes of Health back in the 1980s before medical school. We were studying interleukin 2 and tumor necrosis factor for cancer treatment. Building 10 had mice on the north south axis and human patients on the east west. It was fascinating. Now I am reading a current book on the immune system. There has been a lot of research since 1988. Cytokines are released by cells and are immunodulating agents. They are a form of communication in the immune system.

Killer T cells: When antibodies coat a cell, there are immune system cells that kill and/or eat the coated cells. This is good if it is an infectious bacteria or a cell infected with virus, but it is bad if it is your own joint cells or your heart cells or, horrors, brain cells. In rheumatic fever, antibodies to strep A attack the patient’s own cells as well as the strep A cells. This is called “pseudo autoimmune” but I am starting to suspect that all the autoimmune disorders are responses to stress or infection or both.

So if you are still reading, you are saying wait, this is awful, what can we do about it?

Our understanding of the immune system is better than 1988 however… it still has a ways to go. I think that Covid-19 and Long Haul Covid are going to seriously accelerate the research in this area. Meanwhile there are some things people can do to “down regulate” or quiet down the immune system.

If antibodies are causing some of the problem, we need to quiet them down. With severe PANDAS in children, plasmapheresis filters the blood and filters out antibodies. However, the body keeps making them. Infection must be treated first, but then the initial antibody response lasts for 6-8 weeks. Then the body makes memory antibodies and cells to remember. With reinfection, the response lasts for 2-4 months and then subsides if the infection is gone.

Treat infection first. Then treat urgent symptoms, including urgent psychiatric symptoms. Then work can start on the sympathetic nervous system, quieting down to the parasympathetic state. This is not easy with Long Haul Covid-19 or chronic fatigue or fibromyalgia because people are afraid, confused, in pain, exhausted. I have written about the sympathetic and parasympathetic nervous systems here and here. Start with slow breathing, four seconds in and four seconds out. It takes practice.

I have been getting feedback at the pulmonary rehab. When I arrive, they take my pulse, 02 saturation and blood pressure. They put the pulse oximeter on and often I am up in the 90s. I slow my breathing and watch my pulse drop. One day I came in relaxed and my initial pulse was 71. When I was a little late, it started at 99 and came down. The therapist took it off when I got my pulse down to 90. We can check our own pulse, the number of heart beats in one minute, or a small pulse oximeter is about $30.

We can’t really “fix” the immune system with drugs. Steroids can quiet inflammation but they make us more susceptible to infection and raise blood sugar and cause multiple problems when used chronically, like osteoporosis. Plasmapheresis is expensive and requires specially trained nurses. Doesn’t a breathing exercise sound a lot more DIY and cheaper too? You got this. Practice, practice, practice.

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Parasympathy

In 2013, Catherine Hodes, director of the Safe Homes Project (a domestic-violence program), started a workshop called “Is it Conflict or Abuse?” An abusive dynamic, she argues, requires one person to have power over the other, whereas conflict involves two people struggling for power. The distinction can be confusing, and in some cases “both people feel like they’re being abused, because they’re not getting their needs met or they’re not getting their way.”

From the Atlantic Monthly article: That’s it, you’re dead to me. September 2022 p. 14.

I think this is a fascinating idea, in the article that questions the internet wisdom of getting rid of “toxic people” in one’s life. When we cut off someone we consider “toxic”, we aren’t peaceing them, are we? Peace me, peace you, how do we actively peace people instead of being afraid, on guard, at war. I think everyone is more afraid after the two years of Covid 19 pandemic and all of the deaths and the Long Haul Covid and war. Everyone has a shorter fuse, everyone is stressed.

Remember that stress activates the sympathetic nervous system, the fight or flight system. The body makes less thyroid and less sex hormones and makes more adrenaline and cortisol. Cortisol is a steroid and great for short term, but bad for long term. If we are continually stressed, cortisol messes up the immune system and we get auto-immune disorders, the body attacking its’ own cells. The adrenaline raises our heart rate and blood pressure, neither of which are good for the heart long term. When the thyroid hormone is on the low side, we feel tired. The adrenaline makes us feel wired and we have trouble sleeping. The cortisol makes us more likely to get sick and raises blood sugar too. The low sex hormones, well, women can stop menses and men start asking for viagra.

So we as a world, need to learn to downregulate the sympathetic nervous system and go back to parasympathetic. The relaxed one. The one where we have less adrenaline and less high cortisol and more thyroid and our gut works and sex works again. How do we get there?

Breathing is one way. Slow breathing: 5 seconds in and 5 seconds out. Work up to 20 minutes. One of my veterans said he was not used to feeling relaxed, it felt weird. Ok, it may feel weird, but maybe we need to practice it. He did. There is circular breathing too, 5 seconds in, 5 hold, 5 out, 5 hold. Zen meditation, facing a wall for 40 minutes, works too. We try not to follow the thoughts. The thoughts pop up anyhow, but not following them down the rabbit hole is interesting and challenging. Mindful mediation and Jon Kabat Zinn’s books and tapes work as well. It takes practice. Practice peace, practice relaxing. Doesn’t that sound like a lovely practice?

Stupid cat videos work for me too. Laughter works. What makes you laugh? I like the silly animal videos, the moose playing with the wind chimes, three baby bears rescued (with care) from a dumpster, with the truck driving off to avoid momma bear. Rocking, knitting, sewing, fishing, walking the beach, cuddling a baby, dancing, listening to music, playing music. Which works for you? Silly movies. I don’t like horror movies, and I love cartoons and animation. Engage the child at heart for the parasympathetic nervous system.

In high school my daughter said that most fights were stupid. “One person says something without thinking. The other person goes off and gets upset. She stops talking to person one, who has no idea what is going on, and they often talk to their friends. So there is this big fight over some dumb comment.”

I don’t think it ends with high school, sadly enough. And before we label someone “toxic”, maybe we need to wander off and breathe, or watch a silly cat video. Whatever works for you that doesn’t hurt others.

We need more parasympathy in the world. Yep, I just made that word up. Relax and if you can’t or won’t, consider practicing.

Peace you and please peace me.

https://my.clevelandclinic.org/health/body/23266-parasympathetic-nervous-system-psns

https://healthnews.com/family-health/healthy-living/how-to-activate-the-parasympathetic-nervous-system/

August 19, 2022

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website ethics and mine

Two days ago I wrote to the owner of the website that “separated” me for “not explicitly breaking the rules”.

I have not gotten an answer.

Doesn’t matter, you say. I disagree. I think our ethics matters and it matters on line. Isn’t that part of what we are fighting about?

Let’s drill down. The editors stated on this obscure not to be named site that they were tightening rules and removing write-ups that should be logs or are just not high enough quality, and letting the writers repost them as logs. So far they have removed over 250 of my writeups. Ironically, I was one of the two most prolific writers in the last year. Let’s kill the golden goose because she’s annoying, won’t we? The other writer has not been “separated”.

I note that they have removed my write up called “birth of ——–“. Now, this interests me. This was a well received write up, had up votes, and was the start of a category. The category was people explaining how they chose their on line name.

So: the editors are liars and abusing their power. They have removed a well received and well liked write up because they have personal animosity towards me. I have protested the removal of 250+ writeups and asked that they be reposted as logs. No answer.

The other writeups in the how I chose my name category are still there. So this is PERSONAL and the editors of the site are unethical.

Therefore, I hope the site dies. Or gets rid of those editors. I think I want it to die, even though it has writing by my sister. This does matter. As a species, we will either learn to be fair and human on line as well as off line, or we will end in conflagration. The site will certainly not be there if we start lobbing nuclear bombs at each other. The owner works for the US government. Why is he/she not paying attention to this obscure website that he/she owns?

Whether or not the world burns this month, if the editors are manifestly unfair on the site, the site will die and deserves to die. I wish that I could have my sister’s drafts before it shuts down.

I ended my email that is not answered with this: Good luck. I hope that ethics matters to both of us.

Thank you.

on line site name

_______________________

I will not name the site here or anywhere again, until and unless those editors are shut down and the site becomes ethical.

We are fighting this fight as a species, as humanity. We have to learn to be as ethical on line as we are in person. Well, you say, some people AREN’T ethical. Yes, that is true. As a rural physician, my goal is to take care of ANYONE WHO COMES IN. The emergency room physician cares for the family of four hit by the drunk and the drunk too, even if there is a dead child in the family of four. We set our judgement aside and do the best for each and every patient, regardless of the story. At least, that is the goal. It is the highest goal I know of.

Blessings and be your ethical self on line. As my children said to me when I threw their father out of the house once, “We don’t care what he does. We want you to be polite to dad no matter what.” And they were RIGHT! We answer to ourselves and to the Beloved and to our children.

Blessings.

The photo is me and my sister, dancing before my wedding in 1989. She died of cancer in 2012.

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Playlist: Inimitable

This for the Ragtag Daily Prompt: Inimitable and for the website that threw me out because I “did not explicitly violate the rules”. Yep, that’s right. I am thrown out for or in spite of not breaking the rules. Can you say witch hunt? Or scapegoat?

Oh, man, do I have a song list for the website. And will I name it? Nope. Why would I ever do that? I do have friends there and a mentor. This is not about them. This is about the witch hunters. I curse their tiny brains. And I miss my friends, who outnumber the whiners.

So let’s start with songs by the boys. I’ll do songs by the girls next.

Denial

Hank Williams III: Country Heroes

Bargaining

The Offspring: The kids aren’t allright

Anger

The Offspring: Get a Job

Acting Out

Hank Williams III: Pills I Took

Revenge

The Devil Makes Three: Ten Foot Tall

Grief

The Devil Makes Three: Old number 7

Acceptance

The Devil Makes Three: All Hail

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mask up

Care for your family and friends and community. Mask up and do the best you can not to get nor give Covid-19 this season. The winter is dark but the sun will start returning to us soon. Like the seeds in the ground and the trees with no leaves, we can get through this dark season caring for each other.

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Adverse Childhood Experiences 12: welcome to the dark

Welcome to the dark, everyone.

When you think about it, all the children in the world are adding at least one Adverse Childhood Experience score and possibly more, because of Covid-19. Some will add more than one: domestic violence is up with stress, addiction is up, behavioral health problems are up, some parents get sick and die, and then some children are starving.

From the CDC Ace website:

“Overview:Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing up in a family with mental health or substance use problems. Toxic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. However, ACEs can be prevented.”

Well, can they be prevented? Could Covid-19 be prevented? I question that one.

I have a slightly different viewpoint. I have an ACE Score of 5 and am not dead and don’t have heart disease. I spent quite a bit of time thinking about ACE scores and that it’s framed as kids’ brains are damaged.

I would argue that this is survival wiring. When I have a patient where I suspect a high ACE score, I bring it up, show them the CDC web site and say that I think of it as “crisis wiring” not “damaged”. I say, “You survived your childhood. Good job! The low ACE score people do not understand us and I may be able to help you let go of some of the automatic survival reactions and fit in with the people who had a nice childhood more easily.”

It doesn’t seem useful to me to say “We have to prevent ACE scores.” Um. Tsunamis, hurricanes, Covid-19, wars… it seems to me that the ACE score wiring is adaptive. If your country is at war and you are a kid and your family sets out to sea to escape, well, you need to survive. If that means you are guarded, untrusting, suspicious and wary of everyone, yeah, ok. You need to survive. One of my high ACE Score veterans said that the military loved him because he could go from zero to 60 in one minute. Yeah, me too. I’ve worked on my temper since I was a child. Now it appears that my initial ACE insult was my mother having tuberculosis, so in the womb. Attacked by antibodies, while the tuberculosis bacillus cannot cross the placenta, luckily for me. And luckily for me she coughed blood at 8 months pregnant and then thought she had lung cancer and was going to die at age 22. Hmmm, think of what those hormones did to my wiring.

So if we can’t prevent all ACE Scores, what do we do? We change the focus. We need to understand crisis wiring, support it and help people to let go of the hair trigger that got them through whatever horrid things they grew up with. 16% of Americans have a score of 4 or more BEFORE Covid-19. We now have a 20 or 25 year cohort that will have higher scores. Let’s not label them doomed or damaged. Let’s talk about it and help people to understand.

I read a definition of misery memoirs today. I don’t scorn them. I don’t like the fake ones. I don’t read them, though I did read Angela’s Ashes. What I thought was amazing about Angela’s Ashes is that for me he captures the child attitude of accepting what is happening: when his sibling is dying and they see a dog get killed and he associates the two. And when he writes about moving and how their father would not carry anything, because it was shameful for a man to do that. He takes it all for granted when he is little because that is what he knows. One book that I know of that makes a really difficult childhood quite amazing is Precious Bane, by Mary Webb. Here is a visible disability that marks her negatively and yet she thrives.

A friend met at a conference is working with traumatic brain injury folks. They were starting a study to measure ACE scores and watch them heal, because they were noticing the high ACE score people seem to recover faster. I can see that: I would just say, another miserable thing and how am I going to work through it. Meanwhile a friend tells me on the phone that it’s “not fair” that her son’s senior year of college is spoiled by Covid-19. I think to myself, uh, yes but he’s not in a war zone nor starving nor hit by a tsunami and everyone is affected by this and he’s been vaccinated. I think he is very lucky. What percentage of the world has gotten vaccinated? He isn’t on a ventilator. Right now, that falls under doing well and also lucky in my book. And maybe that is what the high ACE score people have to teach the low ACE score people: really, things could be a lot worse. No, I don’t trust easily and I am no longer feeling sorry about it. I have had a successful career in spite of my ACE score, I ran a clinic in the way that felt ethical to me, I have friends who stick with me even through PANDAS and my children are doing well. And I am not addicted to anything except I’d get a caffeine headache for a day if I had none.

For the people with the good childhood, the traumatic brain injury could be their first terrible experience. They go through the stages of grief. The high ACE score people do too, but we’ve done it before, we are familiar with it, it’s old territory, yeah ok jungle again, get the machete out and move on. As the world gets through Covid-19, with me still thinking that this winter looks pretty dark, maybe we can all learn about ACE scores and support each other and try to be kind, even to the scary looking veteran.

Take care.