angels

The Ragtag Daily Prompt is halo, and I wrote this yesterday, after a discussion with a new friend about angels and my angel dream.

______________________________

angels

light angels fall into dark

dark angels fall into light

there is no separation

we are longing for the Beloved

we are longing to be reunited with the Beloved

we have never been separate

we are one

light falling in to dark

dark falling in to light

seeing both is grace

no separation

Adverse Childhood Experiences 13: on gratitude

I saw a meme today about gratitude. It is saying that some people look at a garden and see thorns and weeds, but others see the roses. That we need to have gratitude. I think this is simplistic and papers over the trauma and grief that some people have. If they have endured a highly traumatic childhood, who am I to say they should focus on the roses? They may have a very good reason to see if there is something like a thorn that can hurt them before enjoying the roses.

I work with many patients with high Adverse Childhood Experience scores and mine is high too. I don’t tell my patients that they should have gratitude. I tell them “You survived your childhood. You have crisis wiring. Good for you. Some of your learned crisis survival wiring may not serve you as well now as it did when you were a child.” Then we discuss whether they want to work on any aspects and the many many different approaches. One example: a man who sleeps very lightly. He said that it was lifelong. When asked about his childhood he says, “We would have to leave in the night when there was shooting in my neighborhood. It was a very dangerous area.” I said, “I am not surprised you sleep lightly. You HAD to in childhood to survive. Is this something you want to try and change?” He thought about it and decided, no. Once it was framed as learned in childhood to survive, he stopped worrying about “normal”. He was satisfied that the way he slept was “normal” for him and he wanted to wake up if he heard shooting.

I think we have to ask why a person sees thorns and weeds in a garden before we judge them. My first thought with a new and angry or hostile patient is always, oh, they have been badly hurt in the past. What happened? I don’t worry that the anger is at me. I know it’s not at me, it’s at the system or a past physician or a past event. Under the anger there are other emotions, usually fear or humiliation or grief. I have brought up Adverse Childhood Experience scores on the first visit sometimes. One person replies, “I am a 10 out of 10.” The score only goes up to 8 but I agree. He was a 10. He stated once, “The military loved me because I could go from zero to 60 in one minute.” Very very defensive and very quick to respond. The response may seem extreme and inappropriate to other people: but it may feel like the only safe way to be to my patient.

I grew up hiding any grief or fear in my family, under anger, because grief or fear would be made into a story told for laughs. In college, a boyfriend told me I was an ogre when I was angry. I started working on it then and it was difficult to tame that. The person who took the longest was my sister: she could make me explode until I was in my residency. Medical training was excellent for learning emotional control, at least, on the surface. After my mother died, I had to do the next piece of emotional work: open the Pandora’s Box of stuffed emotions, mostly fear and grief, and let them out. It was such hard work that my day where I saw the counselor for an hour was harder than my ten hour clinic day. I did the work, for two long years. Blessings on the counselors who stood by me while I worked through it.

I do not think we are ever done with that sort of work. I think, what do I need to learn next? What is this friend teaching me? Why is this behavior frustrating me and I have to look in my inner mirror. Why, why, why?

Blessing on your healing path and may you not be judged.

Link about ACE scores: https://www.cdc.gov/violenceprevention/aces/about.html

Sometimes I do feel like a fossil, now that I am middle aged. For the Ragtag Daily Prompt: fossil.

Is this a tree?

Is this a tree?

I would not call this a tree. I would call it a cone. It contains seeds. It is not a tree.

A pregnancy is called an embryo until 8 weeks after conception and then a fetus until birth. It is not a baby, any more than a seed is a tree. Here is a link to a picture of the embryo developing:

https://en.wikipedia.org/wiki/Human_embryonic_development#/media/File:HumanEmbryogenesis.svg

It’s a bit difficult to call the embryo a baby.

After 8 weeks (10 weeks from the last menstrual period) the developing pregnancy is called a fetus. It cannot survive outside the womb. A term pregnancy is 37 weeks, and the due date is at 40 weeks. The earliest survival, certainly not natural, is around 24 weeks. This takes heavy intervention and technology, a premature infant on a ventilator for months. There is risk of damage to the eyes from high oxygen and risk of spontaneous brain bleed and cerebral palsy, because the newborn can weigh half a pound. Once born, the fetus is termed a baby.

This is important from a medical standpoint and pounded into us as physicians. WHY? Because in a trauma situation, the life of the mother comes first. In Obstetrics and Family Medicine, the life of the mother comes first. In Oncology, the life of the mother comes first. My sister was diagnosed with stage IIIB ductal breast cancer at age 41. She was engaged and it turned out that she was pregnant. She wrote this essay on her blog, Butterfly Soup:

The hardest loss of breast cancer.

She had an abortion and chose chemotherapy, because it was her or the fetus. If she had chemotherapy pregnant, at that time she was told that it would probably kill the fetus or cause terrible birth defects. If she held off on chemotherapy for seven months, her oncologist thought she would die. She had a very very aggressive cancer and she already had a daughter who needed her.

She lived until age 49, with multiple rounds of chemotherapy, radiation, gamma knife radiation, whole brain radiation. And she lived until her daughter was 13. Without the abortion, her physicians thought she would have died when her daughter was 7.

My ethics in medicine are that patients have autonomy. I would NOT have wanted my sister to choose to refuse chemo and try to bring a baby to term while dying of breast cancer. However, it was HER CHOICE, not mine. It was private and no one else’s business and how dare people make moral judgements about another person’s medical choices. I give my patients CHOICES. They can choose not to treat cancer and go into hospice. They can choose surgery or refuse it. They can choose to treat opioid addiction or refuse. They may die of a heroin overdose and I grieve. I try to convince them to go to treatment and I give them nalaxone to try to reverse overdoses. I refuse a medication or treatment that I think will harm my patients, but my patients have autonomy and choices. That extends to women and pregnancy as well.

It is NOT a baby in the womb, however emotionally attached people are to this image. It is an embryo first and then a fetus. And in a car wreck, the woman comes first and the fetus second.

For the Ragtag Daily Prompt: explain.

sand pattern

I took this photograph yesterday on East Beach in glorious sun.

I left the house to hike at 5:30 am. I didn’t hear about Roe v Wade being overturned until later in the day. I am grieving and will fight for women’s right to determine their own health. Each sperm is alive and each egg too. Don’t tell me they should all be saved, because then we would all starve. Life doesn’t start at conception. I think that some men wanting to control women starts with conception. They certainly don’t want their sperm controlled.

In the photograph are great blue heron tracks. I saw at least three great blue herons. At least four eagles, sitting in the tops of trees along the cliffs enjoying the sun.

The beach changes daily. We go to North Beach and one day it is long stretches of sand and the next it is covered with rocks of all sizes. We have been hiking so regularly that it is really clear that the beach changes as much as human moods! Every tide is different.

Here are chalcedony nodules found yesterday. We still call them agates, but since we are getting fussier and want the clear ones, they are more correctly called chalcedony nodules.

The beach changes like US politics. The water rushes in like a new administration, removes small and large boulders and rushes out again. A new Supreme Court Judge, a new person in this appointed position or that, change, change, change, a new pattern. I am grieving about Roe v Wade, but contributing to the fight for women’s rights and for women’s health. I wish that as a country we were less dramatic and nicer and did not need to have an enemy to shout at all the time.

Maybe that change is coming, but slowly. We might learn from social media and from all sorts of lessons. I have some hope.

Meanwhile I’d rather be with the great blue herons and the eagles.

For the Ragtag Daily Prompt: patterns.

soft foot and arms too

Tenderfoot reminds me of my sister and our family’s summer visits to Lake Matinenda. We lived in tents. My grandparents and aunts and uncles and cousins were all in cabins.

We were always the last to head home. We usually mislaid our flipflops, towels, t-shirts and flashlights, so we head down the path in the dark. When I was little I have cuts every summer in the arch of my foot. I learn to walk in the dark on the path with the foot curled and lightly, so that if there is something sharp I can change weight to the other foot. If there are two sharps in a row, usually rocks, I get cut anyhow, but less often. I still love to take my shoes off on the paths there.

I would go this summer except for the oxygen. We did not bring in electricity. I do not quite feel up to acquiring a solar panel/battery combination that is adequate this year. It’s also the heavy lifting. We drink the lake water and bring it up in buckets. We do filter it, but carrying the buckets. It just does not seem like a brilliant idea alone with my lungs still challenged.

Anyhow, here is another soft footed and soft armed creature. This is taken at the Baltimore Aquarium a few years ago.

For the Ragtag Daily Prompt: tenderfoot.

Covid-19: Long Haul III

The CDC has guidelines for Long Covid and it can qualify for disability in the United States.

Here: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html

And here: “As of July 2021, “long COVID,” also known as post-COVID conditions, can be considered a disability under the Americans with Disabilities Act (ADA). Learn more: Guidance on “Long COVID” as a Disability Under the ADA, Section

Here is the list of “most common” symptoms from the CDC:

General symptoms

  • Tiredness or fatigue that interferes with daily life
  • Symptoms that get worse after physical or mental effort (also known as “post-exertional malaise”)
  • Fever

Respiratory and heart symptoms

  • Difficulty breathing or shortness of breath
  • Cough
  • Chest pain
  • Fast-beating or pounding heart (also known as heart palpitations)

Neurological symptoms

  • Difficulty thinking or concentrating (sometimes referred to as “brain fog”)
  • Headache
  • Sleep problems
  • Dizziness when you stand up (lightheadedness)
  • Pins-and-needles feelings
  • Change in smell or taste
  • Depression or anxiety

Digestive symptoms

  • Diarrhea
  • Stomach pain

Other symptoms

  • Joint or muscle pain
  • Rash
  • Changes in menstrual cycles

There are recommendations for a work up by physicians. Depending on symptoms, this may include labs, ECG, echocardiogram (heart ultrasound), CT scan and other tests.

A friend has just gone through those four tests . They are “normal” except for her heart rate. At rest her heart rate is 70 with a normal oxygen level. Walking, her heart rate jumps to 135. Over 100 is abnormal in this athlete who is NOT exerting heavily.

So WHAT is going on with NORMAL testing? I think this is “Covid-19 Viral Pneumonia”, a complication of Covid-19, just as “Influenza Viral Pneumonia” is a complication of influenza. Ralph Netter MD has an illustration of lungs from a person who died of influenza viral pneumonia: the lungs are swollen and inflamed and bruised. WHY is the testing “normal” then? The swelling is throughout the lungs, so a chest x-ray sees it as all the same density and a CT scan also sees it as all the same density. The lungs may have mildly decreased breath sounds, but the sounds are even throughout the lungs. The useful TEST is a walk test. I have tested patients with “walking pneumonia” in clinic for years: get a resting heart rate and oxygen level. Then have my patient walk up and down the hall three times and sit back down. Watch the heart rate and oxygen level. If the heart rate jumps 30 beats up or is over 100, the person needs to continue rest until the heart rate stays under 100 or jumps less than 30 beats. It is important to observe the heart rate until they recover. Sometimes the oxygen saturation will drop as the heart rate comes down, and some people qualify for oxygen. Steroids do not seem to work for this. The length of time to healing is not totally surprising, because a lobar pneumonia that is visible on chest xray takes 6-8 weeks to fully clear. It is not too amazing that a bad walking pneumonia could also take 6 weeks or more to clear. If the person returns to work too soon, they prolong the lung inflammation and they are at risk for exhaustion and for a secondary pneumonia. The treatment is REST REST REST and support.

Do they need oxygen? Currently oxygen is covered only if the person’s oxygen saturation drops down to 88%. However, I think that oxygen would help recovery and make them less exhausted. With my first walking pneumonia, which was influenza, my walking heart rate was 135 and my resting heart rate was 100. Both were abnormal for me. Neither I nor my physician could figure it out. This was in 2003. I did look in my Netter book: I took one look at the painting of the influenza lungs and shut the book. “Oh.” I thought. “That’s why I can’t breathe.” The image is here, though I wish it were bigger.

It took two months for my heart rate to come down, the lung swelling to improve, and me to return to work. I read the text of Dr. Netter’s image a year later and then I read an entire book about the 1918-1919 influenza. Since then I have walked people who come in complaining of exhaustion after a “cold” or “bad cough”. Viruses can cause this and so can bacteria: mycoplasma pneumonia, chlamydia pneumonia, pneumococcal pneumonia, legionella and strep A. If the fever is gone, the infection has probably resolved, but it still can take days or weeks for the lung tissue to recover.

For Covid-19, I would add a third test: walking with weights. We test cardiac patients by asking if they can carry two bags of groceries up a flight of stairs. That is 3 Mets, a measure of the heart load. We need to measure the lung load as well. If the lung tissue is swollen, the amount of airspace is cut down and can be half normal. The heart attempts to take up the slack. The person may tolerate a heart rate of 135 for a while, but it is like running a marathon. If they are older or have heart disease, this can trigger a heart attack. I would walk the person carrying hand weights, and see the recovery.

Also, brain fog is unsurprising. If your oxygen level is borderline, it is darn hard to think. I write really strange songs when I am hypoxic. I get goofy and feel weird. The fast heart rate also feels like anxiety: I think that the body is trying to tell me to rest.

The definition of Long Covid is symptoms after 30 days. Please see your physician if you are still ill and continue to have symptoms.

Blessings.

Here is a recent article about T-cells and inflammation in the lungs of Covid-19 patients: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8460308/

and this: https://www.frontiersin.org/articles/10.3389/fimmu.2020.589380/full

Robust healthful manhood

The photograph of “a healthy man” to go with my Ragtag Daily Prompt conflate post.

I LOVE the caption. “Robust healthful manhood is the source of mental and physical power.” How differently the author portrays health womanhood, as shown in the conflate post. The book is Macfadden’s Encyclopedia of Physical Culture, in three volumes, 1911. Volume I is 500 pages. It is easy to read but it’s a different style from now. Here:

As a rule, if you will simply retain the idea that food should be swallowed at all times without effort, that is, that never, by any means, wash it down with water, milk, tea or any other liquid, that you should masticate it until it seems to disappear without swallowing, you can rest assured that you are masticating sufficiently. p. 97, volume I.

I plan to read the entire set. I think I will find lots of wonderful words for the Ragtag Daily Prompt (hey, I don’t think we’ve used masticate yet!) and material to write about.

Are there still interesting medical ideas out there? Oh, yes. LOTS. Only now they use the internet. I have subscribed to some of the series of videos, telling people how bad and wrong minded allopathic doctors are. Sigh. We do our best. The scam is that they let folks watch one a day for a week, or let them watch one, and then want you to buy the series. “Only $349.99!” Nice scam that is proliferating rapidly. I have now gotten emails saying “Health coaches should make as much or more than physicians and we can teach you how to market and target people and make that money.” Ugh and ick. Really?

I have patients in clinic who present by saying, “I don’t usually go to MD doctors, I go to a naturopath, but I am here because I need an antibiotic.”

I learn to respond gently. “Oh. If you need an antibiotic, maybe you have signs of infection? What are your symptoms?” I have to get past their dislike of allopathic medicine and find out what the symptoms are. Usually if I can diffuse them by getting the story, we can work together. Once in a while it doesn’t work: I have people come in and give me orders. “Do these labs.”

“Uh. Where did this list come from?”

The answer could be a video (by a naturopath, a biochemist, a biologist, whatever. I have watched some of these series. They start by saying that doctors are wrong/stupid/stubborn/misguided/etc.) or a “cash only” doctor or a magazine.

“Why are you coming to me?”

“I want medicare/my insurance to pay for it. I have done my research.”

“Well, medicare does not work that way. I have to list a symptom or diagnosis code for every lab ordered.”

“WHAT?”

I try to be patient. “Every lab has to have an attached appropriate diagnosis code or medicare will not cover it. There is a place in town where you can order your own, but it does not take medicare. You pay for it.”

“Just order it!”

“No. I am a medicare/insurance provider, which means I have a contract with them. It would be fraud and illegal to make up codes. Does your cash only provider use diagnosis codes? Can your bring their clinic note to me?”

One person replies, “My provider doesn’t take notes.” Oh, how nice. That provider does a very expensive panel of labs three times a year that the person is paying for out of pocket. “My provider checks EVERYTHING.” Um, and makes a boatload of money off you too, I think. That patient is very angry that I won’t take her orders and switches clinics. Oddly enough, this does not break my heart.

Some days I hate Dr. Google. There are lots of websites and people on line swearing that they can improve your health. There are scientific looking papers that swear something has been tested, but read the fine print: if the sample is 8 people, how does that stack up against the Women’s Health Initiative, where one arm of the study had 27,000 people? The evidence is weighted. We get multiple articles in medical school and subsequently about how to read a paper, how to weigh the evidence, how to recognize fraud or a poorly designed study.

I do not object to people looking on the internet and I have had people who came in and said, “Is it possible that I have THIS?” and who are correct. However, I see more fraud, always.


behavioral health, cancer, and the immune system

There are more and more articles about immune causes of “behavioral health” diagnoses.

The latest I’ve read is about schizophrenia:

https://www.nature.com/articles/s41598-020-63776-0

Auto-antibodies are antibodies that we make against something else that then attack a part of ourselves. The most well know version of an auto-antibody is Rheumatic Fever, where an antibody to streptococcus A attacks the joints or skin or heart. I had a patient in Colorado who needed a new heart valve at age 10 or 11 because of Rheumatic Fever.

I have written a lot about PANDAS and PANS (respectively Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep A and Pediatric Acute Neuropsychiatric Syndrome) because an older psychiatrist was suspicious that I have PANS. I have had pneumonia four times and it is accompanied by anxiety and fear, part of which turns out to be hypoxia and tachycardia. I think a heart rate of 135 makes just about ANYONE feel anxious. It feels awful.

But what about other Behavioral Health Diagnoses? Remember, we are on the DSM V, the fifth manual of psychiatric diagnoses. We have not had markers or a clear cause. That is, we are aware that serotonin is low in the intracellular spaces in the brain with depression but we don’t know what the mechanism is, what the cause is and what exactly is happening in the neuron or brain cells. A paper on a particular rat neuron said that there were 300 different types of serotonin receptors on that neuron. Blocking one type caused rats to act in an obsessive compulsive manner. But there are 299 others and then combinations. Whew, there is a lot to be learned about the brain.

Fibromyalgia can be caused by autoantibodies, at least some of the cases: https://www.sciencedaily.com/releases/2021/07/210701120703.htm

Chronic fatigue: https://pubmed.ncbi.nlm.nih.gov/34441971/

Lupus and fibromyalgia overlap: https://pubmed.ncbi.nlm.nih.gov/9207710/

Autoimmune disorders are more common in women. We think this is because of pregnancy. The woman’s immune system has to tolerate a pregnancy where half the genetic material is from the father. Yet the immune system also has to recognize “not me, infection” and be able to distinguish that from the pregnancy. This is tricky. The most common autoimmune disorder currently is believed to be Hashimoto’s Thyroiditis, where there are self antibodies to the thyroid. Post covid could potentially beat this out.

Chronic fatigue and fibromyalgia have been orphan diseases in that we do not have an inflammation marker that defines them. The ESR (erythrocyte sedimentation rate) and CRP (um) are usually normal. These are often elevated in rheumatological disorders. Not having a marker doesn’t mean that the muscles are not painful and doesn’t mean that the fatigue is not real.

I am hopeful that we are on the cusp of a true revolution in medicine, with more understanding of the immune system and behavioral health disorders, as well as post covid, fibromyalgia and chronic fatigue. I worked at the National Cancer Institute in the 1980s before medical school, with Steve Rosenberg, MD. He was trying to get the immune system to fight cancer.

Now there has been a cancer treatment with 100% success: an immune treatment for people with rectal cancer with a particular immune profile. This is AMAZING! https://www.zmescience.com/science/experimental-trial-cancer-complete-remission-02725735/

Only 18 patients, but 100% success! No surgery.

The patch for the National Cancer Institute shows a man fighting a crab: Cancer, the crab. Dr. Rosenberg talked about Sysiphus, who was rolling a stone up a mountain eternally while it rolled back on him. From here: Later legend related that when Death came to fetch him, Sisyphus chained Death up so that no one died. Finally, Ares came to aid Death, and Sisyphus had to submit. In the meantime, Sisyphus had told his wife, Merope, not to perform the usual sacrifices and to leave his body unburied. Thus, when he reached the underworld, he was permitted to return to punish her for the omission. Once back at home, Sisyphus continued to live to a ripe old age before dying a second time.

Maybe the stone has reached a resting place. Blessings and peace you. Please peace me.

homage

Homage to the Jubilee and a woman who has seen so many changes. I had two friends over for tea yesterday and had fun dressing up. The suit is made of wool, probably from the 1940s. The gloves were my mother’s. She loved gloves and I have a box. The hat should be pale yellow green too, but this is what I could find.

I am glad that I don’t have to dress this way every day, but it was very fun yesterday. I did not feel encumbered. How DID they keep the gloves clean?

For the Ragtag Daily Prompt: emcumbered.

The first song has tea! And a place in heaven for those who teach in Public School. Sigh.