Category Archives: healing

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Ethical stupor

My friend M is twenty years older than me. A friend of my parents since college. When I went to college in Madison, WI, I got to know her and her husband and their two sons. I lived with them my third year of college and it was a ball! I loved the family.

I visited over the years and more often when her husband had lung cancer and died. She wanted me to come out for her younger son’s fiftieth birthday. Her daughter-in-law said, “It’s nice to meet the daughter.” Apparently M considered me a daughter. I was delighted, since both of my parents had died by then.

A year ago M was feeling less well. She started losing weight. A work up was done, finding no cause. She had a rare cancer that had been treated two years prior. But by July, she had lost thirty pounds.

Thirty pounds! As a primary care doctor, RED FLAG! Very high likelihood of dying, if that went on. She was eighty years old.

I flew out in September. We took a road trip, just the two of us, from Michigan back to Wisconsin. We visited multiple old friends of hers. She thanked me afterwards, because one friend had Parkinson’s and died ten days after our visit. We saw her sisters-in-law and we did a circuit around Madison.

Afterwards, she said that was her last time driving on highways.

By December, she had dropped another ten pounds. Then she had difficulty walking. The daughter-in-law called me. She was having trouble getting any medical attention. They had had trouble for a year! Over a week, M went from walking to not being able to support her weight or stand up. I flew up right after New Years.

Something was wrong, clearly. She’d carried her own bags in September. I was the out of state doctor. The daughter-in-law, B, was moving her from bed to chair alone. I couldn’t. I am 5’4″ and M was 5’10” and now my weight. B found a private practitioner.

On my third day there, M had chest pain. We took her to the Emergency Room. The Emergency Room did the usual things. Then the ER doctor came in. “She is not having a heart attack and she doesn’t have pulmonary emboli. So you can take her home.”

“No, something is wrong! She can’t walk! She could walk two weeks ago! We did a road trip in September!”

The ER doctor shrugged. “What do you expect me to do?”

“Figure out what is going on!”

“She is eighty.” he said. As if eighty meant we stop caring.

“No, we won’t take her home. It isn’t safe. We can’t move her. M, do you want to stay?”

“Yes,” said M.

The ER doctor looked annoyed. “All right. I’ll admit her for placement in a nursing home.”

The inpatient doctor was scarcely more interested.

“What do you expect me to do?” he said, knowing he was dealing with an annoying out of town doctor.

“Steroids.” I said, “Maybe it’s a weird form of polymyalgia rheumatica. She deserves a trial of steroids.”

He too shrugged, and started steroids.

The next day she was stronger, and the third day she could stand. It was SOMETHING, but not clearly polymyalgia rheumatica. The hospital was small and did not have a cancer doctor and did not have a neurologist. They were sending her out on steroids. Follow up outpatient.

We looked at a nursing home, but went to a private assisted living instead. The staff were minimally helpful. We took turns sleeping there. Physical therapy and occupational therapy were started. M was a bit better but not the miraculous return to normal that steroids cause in polymyalgia.

I flew home. The private physician saw her. M was set up to see the U of Michigan. B kept asking if it was lymphoma, because that can be a side effect of the treatment for M’s cancer. M’s cancer doctor said no. M got covid and the appointments were delayed two weeks.

In February she went to the U of Michigan. The neurologists came through and said, nope, not polymyalgia rheumatica, and not neurological. The cancer doctor came through. The GI doctors did an upper endoscopy and biopsied. Cancer. Lymphoma.

M said no to treatment. She was discharged to hospice. She died within 24 hours of reaching the hospice.

The cancer doctor sent an apology to B, who was right all along. This was a particular lymphoma that responds to steroids for a while. M had said that if it was another cancer, she would refuse treatment.

So what the hell is going on here? This: https://www.technologyreview.com/2019/08/21/238642/a-doctor-and-medical-ethicist-argues-life-after-75-is-not-worth-living/

“These people who live a vigorous life to 70, 80, 90 years of age—when I look at what those people “do,” almost all of it is what I classify as play. It’s not meaningful work. They’re riding motorcycles; they’re hiking. Which can all have value—don’t get me wrong. But if it’s the main thing in your life? Ummm, that’s not probably a meaningful life.”

Ok, so now some doctors don’t care once you reach 75. That’s it. They define everything as “useful and productive” and if you are not doing meaningful work, well, you’d might as well die. I hope that doctor does die. Slowly. And that everyone around him refuses to do any tests to see what is happening. And who the hell defines what is meaningful work? That can be helping raise grandchildren, like, hello!

I have another friend who is going through the same thing. She is failing and the medical community in my town is shrugging their shoulders. She should have a head MRI, says the cancer doctor. So that was a month ago and it still isn’t scheduled.

Some of this is pandemic fatigue and backlash. People refusing to get vaccinated, people refusing to believe that Covid-19 exists, doctors and nurses dying of Covid-19, people refusing masks. If everyone is exhausted, what do you let go?

Apparently people over 75. But NOT everyone over 75. If you are wealthy, you will get care. Our Senators and House of Representatives certainly get care after 75. It is the isolated, the rural, the poor, the ones who don’t have an advocate, who will be sent home to die.

I took my friend here to her primary. “What do you want me to do?” he says.

“Here is the Home Health paperwork and she needs disability tags.” My friend is falling, five times that week.

“Ok,” says the primary. “I will set those up.”

When Home Health arrived, she had fallen. She had been down for 15 minutes and unable to get up. Home Health called the fire department. The fire department helped and also came back to put no slip pads on the steps. If she can buy the wood, they will build a ramp for her.

And I will go with her to the cancer doctor and I will rattle cages. She lives alone, she has no children, she has a brother in Alaska. But she also has an advocate. One who knows the medical system and who is not in an ethical stupor.

For the Ragtag Daily Prompt: stupor.

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We change

In clinic, a very common complaint was, “My body has changed!” This was often with shock or annoyance or betrayal. Weight up, a knee hurting, headaches, menses behaving badly as menopause approached, gentlemen with their own problems.

My muscles are getting stronger but are really grumpy. I am starting to rebuild muscle and endurance but my muscles and joint complain. I think that pain is the pain of wisdom. I am clearly very very wise, if that pain is wisdom pain. It feels better to frame it as wisdom than as “Oh, I am old.” Also it’s fun to watch people when I say, “My wisdom is really acting up today.” They get a funny look on their faces.

Medicine changes all the time too. Isn’t that a little unsettling? Science changes, ideas change, frames change. A treatment that I used 15 years ago would not be done for the same problem now. And we can treat hepatitis B and C! Hepatitis C was still named “Non A, non B hepatitis” back when I was in residency in the early 1990s. Hoorah for some things getting better.

It’s been interesting watching the changing ideas about Long Covid. Over the last year they’ve said, “Better in nine months.” “Mostly better by a year.” “Better by two years, mostly.” Also the estimates of people affected in the US have ranged from 3% to 7.4%. There is not even agreement about the definition, with the CDC talking about symptoms staying present after four weeks. Meanwhile the World Health Organization says, “It is defined as the continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation.” Here: https://www.who.int/europe/news-room/fact-sheets/item/post-covid-19-condition. CDC here: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html.

I hope that we vote grown ups into office. I hope we aren’t tempted by the childish want to be dictators who say, “I can fix anything, I can do what I want, I am so great. I can make YOU great too.” I think the pandemic was very frightening and the temptation is to try to hide in an imaginary past or freeze the future or think that if we make everyone behave a certain way, no further pandemics will come. I do not think that will work, people. Vote for adults.

The photograph is from the US Botanic Gardens. Here is the model, inside:

The sculpture faces are over each arch. Here is a close up.

I think the carved face will last the longest, then probably me, then the one on the model. The model looks like it would be delicious for various smaller creatures.

For the Ragtag Daily Prompt: change.

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Home Hurrah!

New Year’s Eve was a travel day for me, flying from Dulles to SeaTac. This time my checked bag came along and did not divert to party in Chicago, as it did on the trip out. I had a wonderful two weeks in Arlington, Virginia and Rockville, MD with old friends and my son and daughter-in-law and daughter. Very kind friends picked me up at SeaTac and drove me the two hours home. I slept for three hours on the plane and another hour in the car. The pair of socks on yesterday’s Ragtag is for one of the two people who picked me up.

The plane was about 40 minutes early and the airport was impressively empty. There was some traffic on I5, but it was not crazy. There was quite a bit of fog all the way home.

Yesterday morning we went to the climbing gym for the second time in the two weeks. I had not climbed in maybe three years? And I have never done a lot.

The rest of my family climbs like squirrels and spiders. I currently climb more like a panicked sloth, but I did a 5, a 5.6 and a 5.7 the first day. Yesterday I planned to take it easy, but I roped up for one and it was the wrong one, so I tried a 5.8. My family was clambering up 5.11s. Whew. It was really fun and loads of fun to watch them. And hurrah that I can climb some after Long Covid and two years with unhappy muscles!

Peace and joy to you and yours.

For the Ragtag Daily Prompt: Hurrah!

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The women don’t see

A man I know is writing about retirement. He says that he has made excuses for years, that he has to travel for work, and not participated with family or entertaining activities.

That work is the only thing he is good at.

I don’t see the problem.

He has four people who have given him accolades for his write up. All men.

The women don’t see the problem.

In college I play soccer. I am not good, but adequate. None of us are really good. We have 12 people. Men and women. I ask a friend to join us.

“No.” he says.

“Why not?” I ask. “You’ve been saying you need exercise.”

“I am not good at it.”

“So what?”

“People expect men to be good at things. You don’t know what it’s like to have that expectation.”

I glare at him. “You don’t know what it’s like to be a woman and have people expect you to be bad at things.”

I knew a veteran. He complained to me about women. “I want a woman who is interested in cars and guns. That’s what I’m interested in.”

“Um,” I say. “Maybe you could develop some other interests? Join a club?”

“No.” he says. “Cars and guns. Why aren’t women interested?”

I am sure that some are. I am also sure that they are expected to know nothing about cars or guns and then are hazed and finally celebrated for being an amazing woman who is interested in cars and guns and has skills and knowledge. How amazing.

The women don’t see the problem with being good at work and not having developed anything else. We often are treated as if we are morons and have a man explain things to us. I have a skill that I have been developing and practicing for decades. Yet a man about 15 years younger than me who is in his first year of practicing, explains it all to me. I look at him and think, you are an idiot. Really. You KNOW I have years and years of experience. I offer to show him another way to do part of it and he soundly rejects and scolds me. “You’ll confuse me! I do it the way I was taught!” I clam up and just think, well, he’s over 30 and still stupid. Bummer. He talks about his amazing development and tells me what he has learned and advises me. Snort. I am ready to take a restroom break the next time he explains what I should be doing. The toilet is more fun than he is.

The women and the single fathers don’t see the problem. If you are raising the kids while working and keeping track of all the stuff: laundry, soccer practice, dentist appointments, helping your 8 year old pick a present for another kid, when is the party and where? Oh, the same day as the parent teacher conferences. Your child may want to do a sport that you know damn-all about or play an instrument that sounds like a rabbit is being strangled or join the young Rotary group. You are not a joiner and view this with an awed horror. But an involved parent will extend themselves into this new unknown alien arena and learn with the child.

And the people who do not have children but are trying to take care of an aging parent or disabled sibling or a long time friend. They too have to learn the systems and the medical one is a deteriorating nightmare labyrinth.

So to say one is good only at work and afraid of retirement: We don’t see it. What are you talking about? We are doing stuff we know nothing about initially as fast as the darn children grow. This month they want their own laptop and are installing linux and “Mom, we need faster wi-fi.” “I am making dinner.” “But mom, the game is timing out.” Huh. Ok, time to call the woman who we know who will explain wi-fi. “Figure out how much it costs, you’ll have to earn part of it if it’s more expensive.” “Mo-ommmm!”

Retirement: begin again. What have you wished to learn, to do, to explore? Be a beginner. Join us. We begin again daily.

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Delicate

I think of what is delicate in all our wide wild world
Our world itself? Yes, but more. Peace among people? No, peace
is strong as war, peace lifts my heart and roars, hoping others hear.
Most delicate is the human heart, all humans. Covid has damaged
the human hearts, we fear, we grieve, we stress and lash out
and so we go to war and wars and argue with each other.
Human hearts turn outward, we cannot see the virus and feel helpless
as the subtle battle is fought and doctors and nurses and scientists
research and die. Human hearts want an enemy they can see, they can fight
and what is better than another human? Every human is different
so there are many choices, to fight over the differences. Let us stop.
Gather our wounded, clear the rubble, find the dead and bury them.
Let us stop and cry and weep and tear our hair.
Let us mourn as a world our dead and the damage to the human heart.

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For the Ragtag Daily Prompt: delicate.

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Covid 19 and the heart

This is from the University of New Mexico Roam Echo PASC (Post Acute Sequelae of Covid-19) talk on 11/9/2023 over Zoom.

Cardiovascular Outcomes in Post-COVID Conditions
Jeffrey Hsu, MD, PhD, FACC, Assistant Professor, Division of Cardiology – University of California, Los Angeles Health and Founder, COVID Cardiology Program – University of California, Los Angeles 

I am going to include the references in the order that Dr. Hsu talked about them. This is a sobering and upsetting lecture with the research showing a post Covid-19 increase in cardiovascular risk factors (cholesterol, hypertension, diabetes), and an increase in cardiovascular events in people with no previous cardiovascular diagnosis including heart attack, stroke, pulmonary embolus, blood clots and sudden death.

I don’t expect the general population to read the studies, but look at a few of them. It is very very impressive, the amount of work being done. Now let’s explore the talk and boil it down to three sentences for primary care to explain in clinic. Right. (You can always skip to the last two paragraphs if you get overwhelmed, and come back later.)

Part 1: The Research.

The first paper is about veterans without cardiovascular disease, followed for one year after Covid-19, matched with a cohort who did not have Covid-19. This is before immunization was available. They were studying the heart and cardiovascular risk. The veterans who had had Covid-19 infection were twice as likely to be diagnosed with cardiovascular risk then the veterans who had not had Covid-19. The risk was higher in the veterans with more severe Covid-19, the risk was present in all subgroups: old, young, male, female, with or without other risk factors. At two years out, the people who had been hospitalized for Covid-19 still had a persistent increased risk of death and cardiovascular incidents (heart attack, stroke, sudden death, blood clots).

To be clear, this is NOT Long Covid patients. This is just a cohort of veterans who had Covid-19. This would indicate that everyone who had Covid-19 has an increased cardiovascular risk.

Here is the first paper: 1. https://www.nature.com/articles/s41591-022-01689-3

Two more papers looked at more general populations who got Covid-19 before the vaccine was available and found the same thing. The veterans tended to be older and more male patients, but the general population studies found the same pattern in women and younger patients. Papers:

2. https://www.scientificamerican.com/article/the-risk-of-heart-disease-after-covid/, “Health modeller Sarah Wulf Hanson at the University of Washington’s Institute for Health Metrics and Evaluation in Seattle used Al-Aly’s data to estimate how many heart attacks and strokes COVID-19 has been associated with. Her unpublished work suggests that, in 2020, complications after COVID-19 caused 12,000 extra strokes and 44,000 extra heart attacks in the United States, numbers that jumped up to 18,000 strokes and 66,000 heart attacks in 2021. This means that COVID-19 could have increased the rates of heart attack by about 8% and of stroke by about 2%. “It is sobering,” Wulf Hanson says.

3.https://www.nature.com/articles/s41591-023-02521-2

Non hospitalized patients had decreased risk for some cardiovascular problems but not all and still had significantly higher risk than people who had not had Covid-19. I am busily thinking UH-OH, this is really bad, in this lecture.

He stated that the data is not in yet about vaccination, whether it lowers the cardiovascular damage compared to unvaccinated.

The initial study was on veterans, mostly male and mostly white, but then was replicated in other similar studies that were not on veterans, but on a general population.

From the second and third study, 700,000 patients with a mean age 40 and more than half female, were studied for new cardiovascular disease in the year following Covid-19 and found an increased risk of death within one year, 0.34% vs 0.28% HR 1.6. That was in 2020, a nonvaccinated population. Another study showed similar results, 13,000 patients with Covid-19 and 26,000 without, average age 51. There was a similar risk increase in cardiovascular disease and an increased risk of death within one year.

4. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00349-2/fulltext

5. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2802095

So do other infections do the same thing? Studies of acute risk of myocardial infarction risk after influenza, done before the pandemic, indicate an increased risk of myocardial infarction within one week after infection, but not beyond that week. So Covid-19 is really really nasty to our cardiovascular system.

6. https://www.nejm.org/doi/10.1056/NEJMoa1702090

7. https://www.nejm.org/doi/10.1056/NEJMra1808137

Pneumonia and sepsis can increase risk of cardiovascular disease, but there have not been the extensive studies as in Covid-19. More and better studies.

One to two years after diagnosis, there is increased cardiovascular and cerebrovascular risk, both:

  1. Cardiovascular risk factors, worsening after covid
  2. Thrombosis risk

8. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(22)00044-4/fulltext

The risk of is up diabetes 40% in the post Covid-19 patients. That does not mean that 40% are diagnosed with diabetes, but that the risk is higher after Covid-19. For example, if in the non-Covid cohort 100 of 1000 40 year olds develop type 2 diabetes, then it’s 140 of 1000 in the post Covid-19 group.

The risk of dyslipidemia in 50,000 patients went up 24%. Dyslipidemia means increased LDL cholesterol or increased triglycerides and lower HDL or all of them.

9. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(22)00355-2/fulltext

10. https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.123.21174

Hypertension is up too and weight gain.

11. https://www.nature.com/articles/s41577-022-00762-9

New onset hypertension is up 22% in hospitalized patients post Covid-19 and 11% in unhospitalized post Covid patients.

Myocardial infarction (heart attack) and ischemic stroke both go up. Ischemic stroke is the more common kind of stroke and is the clotting version. Bleeding strokes are less common.

Why does Covid-19 do this? What is the mechanism? The studies are pointing towards thromboembolism as the mechanism in both increased cardiovascular risk factors (dyslipidemia, hypertension, stroke, heart attack, clots). Thrombosis means clots. Remember the talk about micro-clots? (My write up here: https://drkottaway.com/2023/04/14/xeno-or-infection-phobic/). Micro-clots can lead to bigger clots. A clot in a heart artery causes a heart attack; in the brain an ischemic stroke; a clot in the leg can break into pieces and block the lung arteries. Irritation in the heart and the arteries can increase blood pressure. I’m not sure how it can increase diabetes, but it does.

Next he shows a slide about thrombosis and how complex it is. Sars covid-19 seems to promote perfect storm of events that leads to environment for thrombosis in multiple ways.

Covid-19 infects epithelial cells, causes a hyperactive immune response, orchestrates subsequent response, causes platelet hyperactivation and then hyperactive innate immune response, causes damage to glycocalyx that protects and vascular endothelial injury, decreases antithrombogenic and increases prothrombogenic activity which promotes thrombosis in the vasculature, platelet activation and coagulopathy. Got that? No? Me either, my last immune system class was in 1988 when I was working at the National Institutes of Health. It’s bad, meaning it can kill us or cause damage that is disabling.

12. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30937-5/fulltext

My notes are a bit disjointed here: The endothelial cells (which line arteries) express H2 receptors that Covid-19 virus needs to enter the cells. The H2 receptors are also in glomerular capillary loops (kidneys), and immune cells and cause apoptosis of lung endothelial cells. Apoptosis is a form of programmed cell death that occurs in multicellular organisms and some eukaryotic microorganisms. So you don’t want your lung cells doing that. Lung, small bowel, and pulmonary microvasculature can all be affected.

13. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(22)00355-2/fulltext

Plaque in human coronary vessels, in the immune cells, spike and Sars cov 2 identified in coronary artherosclerotic plaque.

Direct on coronary and cerebrovascular cells. (Ok, I don’t know what I meant by this note.)

Part II: Now what? What is our approach to healing this?

There is still limited data! (The clinical trials are roaring along but they take time.) Here are a bunch of studies, all using blood thinners. Blood thinners include aspirin, plavix, heparin, enoxaparin or apixaban. Do NOT start aspirin at home at this point, because when you add a blood thinner, there is a risk of bleeding, including bleeding stroke and intestinal bleeding. So far, the studies are discouraging.

Aspirin 150Mg Recovery trial: no difference in mortality: major bleeding 1.6% vs 1/0 % Lancet 2022. This is a double baby aspirin dose, 30 days in study, no benefit in acute setting.

14. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30937-5/fulltext

Non critically ill hosp patients ACTIV 4A trial P2Y12 inhibitor – heparin alone or clopidigril (plavix) plus heparin, no benefit, major bleeding 2.0% vs 0.7% so worse in the both group.

15. https://www.nejm.org/doi/10.1056/NEJMoa2103417

16. https://doi.org/10.1001/jama.2021.17272

Harmed patients with severe disease.

ACTIV-4B aspirin or apixiban in outpatient, stopped early, event rate low, higher rates of minor bleeding in the 5mg apixiban group.

Feedom covid 19 trial: Non ICU Hospitalized, compared prophylactic heparin to enoxaparin or apixaban. Signal to provide benefit, lower rates of death and intubation, similar bleeding rates

17. https://www.sciencedirect.com/science/article/pii/S0735109723045278?via%3Dihub

So what does our Post Covid Cardiologist recommend to physicians and patients:

First year post covid: look for cardiovascular symptoms.

Screen for risk factors, hypertension, diabetes, hyperlipidemia, obeisity.

Optimization of risk factors, smoking cessation (and I would add that alcohol also causes damage to the heart and arteries, though tobacco is worse.

Assess candidacy for statin therapy for primary prevention.

18. https://cardiab.biomedcentral.com/articles/10.1186/s12933-021-01359-7

There is a study of triple therapy (meaning THREE blood thinners) that showed improvement but that was in older patients who already have heart disease before Covid-19. So it doesn’t apply.

He says there aren’t any good studies of blood thinners in Long Covid-19 yet and it is not clear that the Long Covid people are worse as far as the cardiovascular risk than everyone else. And remember, these studies are on unvaccinated people, so for the year following the first year of Covid-19. We don’t have the results for vaccinated people. He says that if someone is high risk or has cardiac symptoms chest pain etc put on 81 mg aspirin and a statin (and work it up, of course. Do the testing.

For now use anticoagulation (blood thinners) only if there is clear evidence of thrombus: deep venous thrombosis or pulmonary embolus. Freedom covid-19 study showed major bleed risk 0.1-0.4%.

The cardiologist speaker has not started triple therapy on any patents given unknown benefit at this time, with known significant major bleeding risk. He recommends shared decision making, meaning the patient should be presented with the risks and choices. Um, ok, boil this talk down into three sentences. Good luck. EEEEEEE!

Part III: Summary.

Whether you had Covid-19 before being vaccinated or after, or aren’t sure if you ever had it, it is worth seeing your provider to check your blood pressure, do diabetes screening, stop smoking (anything, and I include vaping in that), reduce or eliminate alcohol, keep your weight reasonable, check your cholesterol and go to your provider if there is any weirdness post Covid-19. And if you have not been vaccinated, oh, my gosh. Unless you have an immunology problem where your immunologist says “NO!”, get vaccinated.

Lastly, I’ve heard many claims that death rates were “over reported” for Covid-19. No. In a death certificate, the acute injury or infection is reported FIRST and then other related causes. Such as: Covid-19, ischemic stroke, hypertension, tobacco overuse syndrome. There were MORE strokes and heart attacks and sudden death, with Covid-19 as the final straw in many people who already had cardiovascular disease. They died sooner than they would have if not infected. That is not over reporting.

____________________________________________________________________________

A friend, Brent Butler, took the photograph, used with permission. I think it shows how I felt after this talk. Yet I still have hope, because you can’t deal with something unless you know about it.

If you want a link for the talks, message me. Anyone can tune in.

Covid-19 continues to fandangle us. There. I verbed the Ragtag Daily Prompt: fandangle.

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Mortal

I am feeling mortal.

I am in my post-pneumonia phase where people say, “Well, you LOOK great.” This is round four, so it’s not a surprise. It just took two years this time, instead of two months. In 2003 it took two months.

There are various things feeding in to this. A friend my age has had a stroke. “NO!” I think, “TOO YOUNG!” The death of the actor from friends bothers me mostly because he’s nearly a decade younger. Drugs and alcohol shorten the lifespan by quite a bit. A study checking for five things: inactivity, drugs, tobacco, alcohol and very heavy weight showed that the people with all five tended to die 20 years sooner than the people with none. That study was at least a decade ago if not two. So cross off about 4 years for any of those, sigh. A cardiologist recently said tobacco is worse than alcohol and now I am wondering how much worse? And how do they measure that? Tobacco kills more but serious alcohol use is a lot faster at killing people. Both of them affect all body systems: GI, heart, lungs, brain, bone marrow, liver, kidneys, and so forth. Even skin.

Also, the last lung test was still abnormal even though I am off oxygen and feeling mostly good. I am having muscle trouble though. Every morning I wake with really bad pain in both thighs and whatever muscles I’ve been trying to build. This has been going on since at least August. Since I think that this is an antibody disorder, it implies that the antibody baseline has risen to the point where my muscles are grumpy and hurt. Alternatively it could be a Long Covid issue: microclots could be clogging the capillaries in the muscles when I exercise and causing hypoxia in muscles, which means they can’t build. Muscle cells are fascinating. When you exercise the cells need more food and build new insulin receptors in the cell wall. So exercise changes the individual muscle cells! How very amazing. My muscles are resisting the build and it is very annoying. There is research going on re the microclots, but there is bleeding risk from the anticoagulants including strokes. So, um, well, I seem to be stuck. It is not stopping me from hiking and dancing and being active but boy does it hurt in the mornings.

This is not very bucolic, is it? I am still attending the Long Covid talks and it is really fascinating and quite scary. It’s just a very very nasty virus. I wish it would calm down. The 1918-1921 influenza really calmed down after three years, but there are no guarantees. Anyhow, at least I can dance!

For the Ragtag Daily Prompt: bucolic.

The photograph is taken in Michigan in 2014.

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Messy

Everyone I get to know and really become friends with, has a messy life with difficulties. I think we are terribly afraid to admit it, with the curated lives on the place that is not a book but has lots of Faces. I write that all of my patients are smart and they are. I had my own rural family practice for eleven years. My goals were more time with patients and to do good medicine. I succeeded at both. With more time, I could learn a little more about my peoples’ lives. People that I would never suspect of having very messy lives still have them. Does everyone in our culture have estrangements, family that they don’t talk to, parents that they find difficult, friends that they have gotten upset at and abandoned?

In high school my daughter says, “Most of the fights are stupid. Usually someone says something without thinking, even in passing. Person B takes it personally, gets upset, talks about it to others and then person C or D says something back to person A or shuns them. Person A has no idea what is going on and is hurt and upset. It is stupid.”

Adults do this too. I had a friend where I would think about something for a week and then go back to him. “You said this. What did you mean?” Usually he didn’t mean anything or meant something very far from what I was thinking. At least I went to him and did not add person C or D or E to the mix. He said, “You think about it for a WEEK.” Well, that was his own fault, actually, because he can’t tolerate anger. Even if I was upset or hurt, it was still interpreted as anger. Raised in an alcohol household and trained by medicine, I can hide feelings. After a while he could tell when I was chewing on something.

We grow up physically by our mid twenties, but often we don’t grow up emotionally. Especially if relationships are interrupted and colored by drugs and/or alcohol. People miss developmental stages. Everyone is trying to cope as best they can, but I do wish our culture celebrated mature calmness and quiet adulthood, rather than just the wild youth. Wouldn’t that be a change?

If you were to curate your life for something like the site that is not a book and has Faces, what would your ideal be? What do you aspire to? Kindness? Emotional maturity? Peace? My feed has friends, insects, birds, rocks, fossils, funny animal videos and music. I get almost no politics in it. I have not blocked anyone or anything. I try not to friend people I do not know. It is peaceful and a celebration of nature and yes, that is what I would like to curate.

Blessings.

For the Ragtag Daily Prompt: curate.

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Marijuana update

https://newsroom.heart.org/news/marijuana-use-linked-with-increased-risk-of-heart-attack-heart-failure

Marijuana is still illegal at the federal level, but some states have legalized it. I agree with legalization but I don’t think of it as benign or safe at all. It’s clear that it can be addictive. A study of teens (with parental consent and where they paid the teens to try to quit for a month) showed that the teens that smoked daily had real trouble stopping, even when quite motivated. The U of WA Pain and Addiction telemedecine said that about half of daily users have “overuse syndrome” and have trouble quitting.

I worked with two people who were trying to quit. The big issues for them in quitting were insomnia and anxiety. Marijuana can suppress both anxiety and help with sleep. However, our brains do not really like that sort of daily interference. The neurons can remove receptors from the cell walls if they are feeling overwhelmed. It is like trying to listen to music with ear plugs. You turn the music up. The drug is the ear plug: when the earplugs are gone, the music is way too loud. We can’t really “turn the music down”, so it is not much fun letting the neurons recover.

With the edibles and THC vs the other one, it’s even more confusing. I had many patients taking edibles or tinctures to sleep. Some said, “Oh, it’s CBD, so it doesn’t make me high. So it is not addictive.” We do not know it that is true. With opioids, people can have opioid overuse syndrome without ever getting high, just from being on pain medicine as directed. And marijuana does not have only CBD and THC. There are over 300 different cannabinoids in the plants, and CBD and THC are just two of them. I have no idea if the edibles and tinctures have the other 298 or more and what they do to the cannibinoid receptors in our brains alone or in combination.

I don’t want to have any overuse syndrome: alcohol, opioids, gambling, marijuana, whatever. I know I can get off caffeine in 24 hours, though it involves an awful headache. I am nearly off coffee now, because my body only likes coffee when I have pneumonia. I quit coffee from 2014 to 2021 and now am quitting again.

The two studies in the article look at people who do not smoke tobacco and who are using marijuana. They are seeing an significant increase in heart disease, heart attacks, sudden death and congestive heart failure. Congestive heart failure is pump failure, where the heart does not pump correctly. This is a major problem, as you might guess.

Be careful out there.

I took the photograph at Fort Worden last week on a day where both the wind and the tide were howling.