Category Archives: hope

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Balancing act

I am working at a site in the greater Seattle area, but I am not going to say where. Why? Two reasons. One is that the patient diversity is huge: the organization is organized to take care of low income, uninsured and immigrant patients. The second is that I am still trying to decide if the balance of the organization is working. It may be working but it might not be working for me.

I am at a large clinic, with primary care, dental, behavioral health, a nutritionist, a pharmacy and three in person translators. In any one day I will probably use translators for at least six languages. English, Spanish, Dari, Hindi, Punjabi, Arabic, French, Somali and sometimes languages that I have to look up the country because I don’t know where that language is spoken. The work is fast and furious.

The overall no show rate is 20%. This makes the day very unpredictable. It can be very very fast and busy with everyone showing up and then later there are three no shows in a row. I think that the no show rate has been less than 20% but on Tuesday it was more. However, everyone showed up in the morning and there was a hospital follow up that should have had 40 minutes and only had 20 and of course then we ran later. My lunch theoretically starts at 12 but I went to lunch at 12:50 and came back 6 minutes late, at 1:06. Then people no showed while I worked to finish off everything from the morning. It did feel a bit nuts.

We are using the electronic medical record EPIC. I find EPIC epically frustrating. It is “feature rich” which means it has too many ways to do things. If I ask someone how to record a phone call to a patient, it takes eight steps. A week later I have to do it again, I ask again, and the next person shows me a DIFFERENT set of eight steps. And there have to be at least eight ways to do anything, so it is very confusing. Also, the “home” page can be personalized to the extent that people look at my version (I have not personalized it much) and say, “Mine looks different. I don’t know how to do that on yours.”

Whew. So, how to cope with the fast furious unpredictable schedule? I am “precharting”. For this Tuesday, I spent 70 minutes going through the patient charts on Saturday. Then I may know why they are coming in, if they had a heart attack two weeks ago and are following up, if it is a well child check and the last one was two years ago, if there are outstanding issues like a elevated liver tests or they have not been in for their out of control diabetes for a year. Then, of course, some of them do not show up. It is so busy that all I feel when someone no shows is some relief, like a ray of sunlight in a dark forest. Ok, the person who was horribly sick and in the hospital for a week and had surgery, they really do need to follow up. But I cannot make them, no one can.

We have live translators, outside translators who come with the patient, family sometimes translates and two phone translation systems. Our live translators cover the following. One Spanish only, one Dari, Arabic and ?maybe Russian. A third language. The third does Hindi, Punjabi and something else. I can’t tell by language who is a recent immigrant or refugee or who is a citizen of the United States for thirty years.

The clinic system has high standards for care of an often vulnerable population. However, I have not decided if it falls into a statement by my grandfather: “The higher the ideals of an organization, the worse its’ human relations.” My job in Alamosa had very high ideals, but I was fifth senior doctor out of 15 in a mere two years. A burnout job. This one has three new doctors coming in soon. My training and assistance to learn EPIC has been sparse and not up to my standards. If the new doctors are treated the same way then this is a burnout job as well. This is a place that I could work in intermittently alternating with other places in the country, but only if it is balanced for both the patients and the physicians. The jury is still out, but there are many red flags. It is a six month job and I am two months in, so we shall see.

Hugs to everyone.

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For the Ragtag Daily Prompt: nuts.

The photograph is from Larrabee State Park this weekend. My daughter came out and saw many of her friends, stayed with me, and we camped for one night at Larrabee.

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Concord

my heart is broken
love doesn’t conquer all
unselfish love
unreturned
unrequited
opens me to wound after wound
some turn from love no matter what
cling to the lies they tell themselves
cling to the poison they embrace
turn from love into the uncaring bottle
turn from love into the insensate smoke
turn from love even to the grave

I wish my heart would let them go
and heal

__________________

My friend Liz took the photograph, half way through the Rainshadow Chorale concert last Sunday.

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Alcohol myths

I am back working in Colorado and a recurring theme this month is alcohol and alcohol myths.

Myth: If I only drink on my days off, I am not an alcoholic. Nope. People can binge one day a week and still be an alcoholic. A standard “dose” of alcohol is 12 ounces of 5% beer, 5 ounces of standard wine or 1.5 ounces of liquor. But what if someone drinks 8% beer, 12 ounces? Well, that’s 1.6 standard drinks. An 8% 16 ounce beer? That is 1.6 times 1.3, so 2.08 drinks. Perhaps we should have an app that calculates this. And locks the car ignition when we are over the limit.

How much alcohol means that we are an alcoholic? The guidelines right now in the US say 7 drinks per week maximum for women, 14 for men, no more than one in 24 hours for women, no more than 2 in 24 hours for men and no saving it up for the weekend. Here: https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/basics-defining-how-much-alcohol-too-much#pub-toc3. However, alcohol is bad for the liver, bad for the heart, bad for the brain, and increases cancer risk. There is not a “safe” amount.

What is binging or heavy drinking? For women—4 or more drinks on any day or 8 or more per week, For men—5 or more drinks on any day or 15 or more per week. The rate at which people drink is also part of this.

MYTH: If I don’t throw up, I’m not an alcoholic. Now that’s an interesting one. When we drink, alcohol is absorbed into the blood and goes through the liver. The liver has enzymes which break alcohol down into aldehyde. Aldehyde is a carcinogen, causes cancer. Aldehyde is broken down by other enzymes into acetate and then to carbon dioxide and water. Some people break down the aldehyde quickly, fast metabolizers. They can drink a lot and not throw up because they break the aldehyde down fast. However, the process inflames and kills liver cells. If they keep drinking, the liver slowly dies, and this is cirrhosis. Eventually they will not be able to break down alcohol fast because the liver makes the enzymes. Then they will start throwing up.

Other people make enzymes that are slower or make less, and they get sick and have alcohol poisoning more quickly. The fast metabolizers are at higher risk for cirrhosis and the slow ones for liver cancer, but they can get either.

MYTH: “My blood pressure is fine.” I spoke to a person who stated that their blood pressure was ok during pregnancy so they did not have high blood pressure. The chart shows very high blood pressure for the last three years and I didn’t look back further. I ask, “Did you stop drinking alcohol while pregnant?” “Of course.” When NOT pregnant, this person admits to 4-5 drinks a day. Also, the history in the chart states that they had blood pressure complications in pregnancy. I did not have time to go through the chart and look at that, but this person is in denial. I think of denial as the addiction taking over and the addiction lies. It lies to me but it also lies to the person. They want to believe what they say. They want everyone else to believe what they say even if it is patently a lie and ridiculous. A woman who says a friend gave her something, she didn’t know what it was, for a headache. “How did you take it?” I asked, looking at the urine dip results. “I snorted it.” “So what things do you snort for a headache?” She was positive for cocaine and pleading ignorance was ludicrous. Another person has a positive urine drug screen for multiple things. “Can I try again?” Pause. “Sure.” I say. The first one is a false sample and I am very curious to see what the real sample will have. It has nothing. He is then surprised that I won’t fill his prescription and offer inpatient drug rehabilitation. Come now, sir, you got a urine sample from a dealer when you sold the medicine I gave you for something else. Your dealer must have been annoyed or gave you the wrong sample. When someone is really out of control, they do not have convincing lies and the only person they can convince is themselves. It is interesting to watch someone be all outraged that I do not buy the story, accusing me of discrimination or hating them or hating their race or whatever. They attempt to accuse and distract. It is harder for families because they desperately want to believe their loved one, even when the evidence shouts the opposite.

What does blood pressure have to do with alcohol? Alcohol drives blood pressure up and pulse, especially when it is wearing off. Severe alcohol withdrawal is delerium tremens and people can have such high blood pressure that they have a stroke or a heart attack or encephalopathy — a poisoned brain. They can hallucinate or have seizures and it is very dangerous. “Very dangerous” means they could die or have permanent disability. Tobacco, cocaine, methamphetamines, all raise blood pressure. The number one cause of death in the United States is the heart, but it’s not just from hypertension and weight and cholesterol and inactivity. Addictive drugs have a huge contribution.

There is nothing cheap about the cost of addiction in our country.

For the Ragtag Daily Prompt: cheap.

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Taste

I am back in Colorado for another work stint.

I am in a different house.

I am in a neighborhood, of cul de sacs that don’t connect. My house is quiet in front but backs on a very busy road, an artery. The speed limit is 40 mph but people often go faster.

The house seems odd to me. There are curtains and shades on every window, all closed when I arrived. I open them, because I like light. There is a 3 by 4 foot television in the living room, another in the master bedroom and a third in a guest bedroom. There is a large kitchen with tons of shelves and cupboards, but a table only seats two, and there are two more chairs at the counter. This feels very odd to me. It seems as if the whole house is arranged to watch television.

I go for a walk in the neighborhood. There are many houses. There are beautifully trimmed lawns and there are flowers and some roses. What is missing? There are no people. Walking a mile and a half, finding the mostly hidden corridors from one cul de sac to the next, I see one man working on his lawn. Even though it is Saturday afternoon, I seen no children, no dogs, no toys. I see two garages that are open, one with a man and in the second I hear a child. Why are there beautiful lawns and no people? And many of the lawns have little flags saying, poison sprayed.

I do turn on one of the televisions after my first day of work. The living room one says that the antenna is not hooked up. The guest bedroom one works. I look on the service. Nearly every movie is about violence and conflict.

I do a little research on the internet. I go to the library and take out 8 books. One is Nonviolent Communication, by Marshall Rosenberg, PhD. Most of the others are fiction. Yet so much fiction is about conflict too. Good triumphing over evil. I am pretty good at nonviolent communication in clinic after 30 years: I want to meet each patient somewhere that is helpful. Sometimes they don’t like what I find, or don’t want to do what I recommend, but I have a deep and abiding faith that everyone can change, that they are smart, that I can make a difference and that they are capable. I think that belief helps daily in clinic.

I choose this book because I want to be better. Some of my family is estranged. I thought that was rare and horrifying at first, years ago. Now I think that it is horrifyingly common, much more common than I realized. How do we heal this? What can we change? I don’t want to be in a dark house with the shades down watching “good” triumph violently over “evil”.

There is a pond, man made, with a fence around it, half a block from my house. There are two male mallards, a female, and eight ducklings. They are fuzzy and delightful. I stop my car and watch the first time I see them, and I walk over too.

I haven’t seen anyone else there. I think we can change. I have hope. I have a deep and abiding faith that we can change.

For the Ragtag Daily Prompt: garlic.

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Friends forever no matter what

My small child self is happy
Happy inside
She loves who she loves
Living or dead
In contact or fled
Distant or close
She loves who she loves
And I hold her close

My adult self is happy
Happy inside
I love who I love
And the world is so wide
Living or dead
In contact or fled
Loving forever
No matter what happens
I love who I love
My heart holds them close

My small child grieved losses
I hold her close
She loves them all
I guard her from most
She stays friends forever
No matter the grief
She is happy in loving
Her loves shine as stars
The ones who are hurtful
Are loved from afar
She’s held and she’s loved
And her love sings unmarred

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For the Ragtag Daily Prompt: dogwood and for Mother’s Day. Mine died 25 years ago.

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Purity’s post

The root word for Katherine is pure, so Purity will write today’s post. Purity read about illeism in this BBC article: https://www.bbc.com/worklife/article/20230411-illeism-the-ancient-trick-to-help-you-think-more-wisely. Purity admits that it feels a bit embarrassing to write in the third person here on the blog, very egotistical, but that is not what the article is about. It is about writing that way in one’s journal. Purity has been trying it and it is interesting. It sets events at a distance and quiets and muffles the emotions related to events. How very curious.

Purity does not plan to keep writing this way on the blog nor does she plan to start speaking with a royal we. However, the United States appears to be in a state of chaotic stupidity and it is affecting everyone. Not just in the United States, but the rest of the world as well. Purity thinks of the United States as a teenage country, struggling with hormones, while the old countries stand back, watch and sigh. “At some point he will mature,” they say to each other. “Or destroy himself.” And yes, a male teenage country, stupid and boastful with testosterone. Purity thinks it will take the United States another 200 years to live down President #47 and his minions, if we survive.

At any rate, Purity hopes that the prompt of illeism might be more light hearted and be a new word to some people and tickle their fancies. Apparently our fancies mostly lie in our cats. Cats certainly seem to be experts in illeism. May you each feel as wonderful today as a cat when they own the world.

For the Ragtag Daily Prompt: illiesm.

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Vision

What will peace look like? People
will still disagree often
but like my parents they will appreciate
evidence and science. They will listen
to each other with interest, with respect.
They will bet a penny or a quarter or a million
imaginary dollars and one will go to look up
the correct capital of Azerbaijan, while
the other argues that they MEANT back in 1478,
really, so they do not owe one million imaginary
dollars and they both start laughing again.

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The photograph is of the ice in Echo Canyon, two days ago. Or maybe it is angels, waiting.

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Pick one, delete two

I went through my blog this morning, picked a month two years ago, and deleted a bunch of photographs and the accompanying posts. More room! It is not a very fast process.

I am thinking about the Ragtag Daily Prompt today, hamfatter. It makes me think of Miss Piggy first. Don’t we all have a little bit of ham in us if we are in the right situation? Even if it’s just a dream or a daydream. Hamfatter also brings up ham and my inlaws. My son and daughter-in-law and daughter were all home for my birthday earlier this year. We also stopped at my daughter-in-law’s house, to pick my son up. Her parents heard it was my birthday and gave me a ham. How surprising and kind!

Yesterday I ordered prints of photographs to send to them, almost all with their daughter. She told me not to print any of the climbing gym or of the pets that her mother dislikes. Got it! I tried to pick ones that they will enjoy. It is a start of holiday gifts.

I am still having disaster nightmares, last night about my house. My house is far away right now and apparently my brain is worrying. I dreamed that there were clean baby clothes folded and piled all over the place in the upstairs bathroom, even on the commode. I took them off it and discovered that it was backed up. Then the walls dissolved and I realized with horror that there was water flooding through them! Then I woke up. Not a fun dream and no, there are not clean baby clothes in the upstairs bathroom. I think it is a combination of being far away and the coming administrative change. In some states it is illegal for a physician to discuss abortion. Will vaccines be next? And the most abortions are the spontaneous ones, where the pregnancy ends and passes. We call that a miscarriage but it is also called a spontaneous abortion. I wonder if those are illegal too.

I dress a bit more formally for work then at home. Maybe there is a bit of hamfatter there, too, entering the role of doctor.

I took the photograph in 2007.

For the Ragtag Daily Prompt: hamfatter.

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Low fog

I took this on New Year’s Eve on a walk with my kids and old friends in Maryland. We fooled around in a park. I like the low fog hanging in the trees, always further away when we walked to it.

Seesaw, Margery Daw, Jackie shall have a new master
He shall have but a penny a day, because he can’t work any faster.

That is the version of an old nursery rhyme that I learned from my mother. There is more about it here.

I am going through and starting to delete old blog posts and photographs to make room for the new ones. Not one of my stronger talents!

For the Ragtag Daily Prompt: seesaw.