Category Archives: medical billing

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Eating sunlight

Beloved
I don’t think I can bear this
It’s a good plan
To work five more years
And retire in better financial shape
House paid off
But it hurts so

My tattered bruised and battered heart
Already patched so many times
And to see so many people each day
Hurting

Why, Beloved?
Why don’t we mature?

Maybe I’ll be a tree again
Living wood
That bends and moves with the wind
That eats the sunlight
Drinks the rain
Endures the snow and drinks it as it melts
Until spring comes
And I stir and start to bud
Deciding when it’s time
To uncurl leaves in warm sun

_______________________

For the Ragtag Daily Prompt illusion. Or should it be delusion? Or survival? Or beyond that to peace?

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The isolated working

I ran my own small clinic from 2010 to 2022, working somewhere else, got Covid, was on oxygen for a year and a half, did some healing and then came back to work.

There has been a culture change in medicine that feels very strange to me. I did not notice it because I was in a solo clinic and not “part of the system”.

All the doctors, providers, are more isolated. I got a compliment yesterday when I was doing a “warm hand off” of the most sick or complicated patients, three new diabetics, a person with cancer, a person with a genetic heart problem. The doctor who I was handing off to is in the same clinic but we have barely talked since May. I don’t know her at all. She complimented me on excellent care “and calling specialists”.

I thought, huh. But I think that is a dinosaur doctor thing. I think mostly people communicate through the electronic medical record email, send messages about patients. For the decade that I was solo, I had to call other specialists because I was on a different electronic medical record. The email didn’t connect. The hospital reluctantly gave me a “link” to their system, but it was only a link to look. I could not write or send anything.

About two months ago I got an echocardiogram result. I read it and thought, ok, it’s not normal but what does it mean? Outflow obstruction by the thickened heart wall. Hmm. I called cardiology and spoke to the cardiologist who read it. He sounded surprised and said, “Idiopathic hypertrophic cardiomyopathy, most likely. It’s a classic echo.” “So, what do I do?” “Send him to me.” “Anything that I should change meanwhile?” “Yes,” says the cardiologist. He had me stop one medicine and start another. “No vasodilators and the beta blocker slowing the heart rate should help decrease the outflow obstruction.” “Got it.” I said. He also gave me two more tests to order.

I referred the patient to cardiology but it was a month before he got in. The two tests were done and they ordered more. If the diagnosis is correct, he’ll be sent to a special clinic in Denver. I called my patient while we were waiting for the cardiology visit. The medicine change had not made much difference as far as he could tell.

I was also told when I got here that I would never get a local nephrologist to see a patient, they were two busy. However, I have called two nephrologists about two patients and both took the patient and again, gave me instructions.

Two specialties have been very difficult to contact: orthopedics and gastroenterology. I have no idea why they are so difficult.

I can see that email feels faster. But there is no human contact, asking follow up questions is difficult, I don’t get that bit of further helpful education: this is what you do next. I have learned so much over the years by touching base with specialists. Once I fussed at a patient to go to hematology oncology about their high platelet count. The patient didn’t want to. He came back and said, “Apparently I have this newly found genetic problem. They put me on two medicines, not expensive. And I feel better than I have in 20 years.” I asked the oncologist about it the next time I called. He lit up, excited, and told me about the JAK-2 mutation. It is so exciting to learn about new areas in medicine and my patient says, “I have to thank you for pushing me to see the oncologist. I feel so much better.” Wow and cool.

Clinic feels like I am mostly isolated, a silo, an island, rarely talk to the other physicians unless I go to find them. I think hospital administrations like this, keeping the physicians in line by having their schedule be so packed that they almost never talk to each other. What a good way to keep physicians from interfering in the money making production! Ugh, I think it is quite horrible and unhealthy for the providers and for our countries medical system in the long run. I was seriously less lonely in a solo clinic.

The prognosis for our current medical system is very poor. The patients say to me, “Why do my doctors keep leaving?” They aren’t attached, they are isolated, I don’t think the physicians know what they are missing. Colleagues. Not silos.

For the Ragtag Daily Prompt: prognosis.

The photograph is from the Fruita Fall Festival.

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A yarn about paper

On Friday in the morning I took notes on paper. I was attending a conference on diabetes on Zoom. There are three new things added to the diabetes guidelines. It is now impossible to do a visit about diabetes and actually talk to the human being who has diabetes. We’ll be too busy doing the stupid checklists.

The personnel person stopped by. I said I was taking notes. “On PAPER? You are killing me!”

“Ok. I will use yarn this afternoon.” I drove home and got my knitting and worked on a sock in the afternoon. All the clinics were having a slow day. I guess the kids are getting out of school and everyone is feeling good. Or panicked.

I retain as much information knitting as I do taking notes. Tactile-auditory learner and the controlled fidgeting of knitting helps me stay awake, retain information, and produce socks and others items. I wear the socks more than I reread the notes.

I still like paper. I keep a paper journal. I wanted notes from the most complex lecture. The new medicines are jockeying for position but right now there are different indications for each one, so it’s rather confusing. They said that Type II Diabetes takes two hours daily to manage “correctly”. And that Type I and Type II on insulin take 3 or more. We are supposed to check for Diabetes Distress, which is not depression, exactly. I think I need to be checked for Guideline Distress and Contact Diabetes Distress, sigh. At least the Diabetes Distress speaker thought we should talk to the patient, though I think the talking should have been long before that. Medicine in the US is a mess.

I used the back of the clinic schedules for notes. I do print it out daily. It’s to try to run on time. What time am I supposed to see the patient, but they can be up to 7 minutes late and then the medical assistant still has to “room” them (yes, room has been verbed). Then I can go see them. So the theoretical starting time and the actual starting time can vary quite a bit. I don’t feel bad about being twenty minutes late if I didn’t get to go in the room with the last patient until twenty minutes late. Maybe a no show will let me catch up. Or not.

Anyhow, I still like paper.

For the Ragtag Daily Prompt: paper.

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Integrated behavioral health

The buzzwords now in Family Medicine. Integrated behavioral health in primary care. I am finding it a bit annoying.

Integrated does not mean race in this context. It just means the clinic should have a behavioral health person.

I suppose that is a good idea maybe, or might seem like one. But what do they think I have been doing for thirty years? Ignoring behavioral health?

Really, primary care is half or more behavioral health, if a primary care doctor gives people time and pays attention. People have an average of 8 colds a year. Why do they come in for cold number 4 if it is no worse than all the others? Because the cold in not really why they are coming in. The cold is the excuse. Notice that the person is there, that they are not that sick, that they do not care that you are not going to prescribe antibiotics.

I have my hand reaching for the door when an older patient says, “May I ask you something?” She came in for something that she didn’t seem to care about, so I am not surprised. I turn back. “Yes.”

“I have friends, in another state. They had a baby. The baby is very disabled.”

I sit down. This is more than 15 years ago, so I do not remember what the baby had. Hydrocephalus. Cerebral palsy. Something that requires multiple doctors and physical therapy and the parents are grieving.

“What bothers me most is that they have to struggle so much for services. There is very little support and very little money set aside. One of the parents has quit their job. It is a full time job taking care of this child and they are frightened about the future. Is this really what it’s like?”

And that is the real reason for the visit. “Yes,” I say. “It can be very difficult to access services, you have to track down the best people in your area, some physicians won’t pay much attention and others are wonderful. And the same with physical therapists and everyone else. Tell them to find some of the other parents of these children. Get them to recommend people. And the parents have to be sure to take care of themselves and each other.”

She frowns. “It’s a nightmare. Their life completely changed from what they thought. First baby. And it is overwhelming.”

“I am sorry. You are welcome to come back and ask me questions or just talk.”

“Thank you. I might.”

“Do you need a counselor?”

“No, I’m fine. I am just worried about them and feel helpless.”

“It sounds like staying in touch is the best thing you can do.”

“Ok.”

The true reason for the visit is often something entirely different from what the schedule says. Sometimes people are there without even knowing why they came in. “Can I ask a question?” That is key. Saying to see people for one thing is criminal and terrible medicine and makes behavioral health worse. There is so much we can do in primary care just by listening for these questions and making time for them.

I have nothing against adding a behavioral health person to the clinic. They talked about “embedding” a behavioral health person in each group of soldiers back in 2010, when I worked at Madigan Army Hospital for three months. I always pictured digging a hole in my clinic floor, capturing a counselor, and then cementing them in the hole. I would have to feed them, though. I always thought that was sort of a barrier. One more mouth to feed. I found it more useful to contact counselors, ask what they wanted to work with, learn who knew addiction medicine, learn who was good with children or families or trauma. And ask patients to tell me who they liked and why. I integrated behavioral health in my community, not just in my clinic, because there is no one counselor who is right for everyone.

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Rebel in clinic

Right before my hospital district informed me that they no longer wanted my services, I was rebelling. The fight from my perspective, was over good patient care. They had set a quota. 18 patients a day. One every 20 minutes and one 40 minute visit. 8 am to noon and 1 pm to 5. I argued and argued and argued. I knew finishing the note in the room took me 25 minutes on the hateful electronic medical record and I had averaged 16 patients a day my whole career. I was not fast but I was super thorough and had just gotten an excellent report on a chart review and had been told that I was a great diagnostician. Which was mostly due to my nearly OCD thoroughness. I was not diplomatic with the hospital administration.

One day I was feeling wicked, just wicked. I had a brainstorm and started whistling softly. The other two doctors and PA were all in the same small office.

One took the bait. “What is that? I know that song.”

“Oh, we are singing it in chorus. For some reason it is in my head today.” So I sang this song.

I did not have the words memorized. I swear that the temperature in the room dropped and the male doctors hunched in their chairs.

“Yeah, don’t know why that one keeps playing in my head.” I said. “I hope you can all come to the concert!”

But answer came there none.

I took the photograph at Quimper Family Medicine, the clinic I opened after the hospital clinic kicked me out. The skeleton was named Mordechai in a contest. This is from 2014. Mordechai lived in our waiting room every October, with different outfits.

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Update on whatever it is I have

I had the heart echocardiogram bubble study. Normal. I really really did not like having the mix of blood, saline and AIR injected and I COULD FEEL IT. My logical brain knew it was going into a vein, but my emotional brain kept yelling “Air embolisms kill people!” Yes, but that is arterial. My emotional brain did not care. Anyhow, it was fine.

Saw the cardiologist who said he can understand why I feel PTSD going into my local hospital. He says I should not need oxygen at age 60 with no smoking. He says “Not your heart.” Yeah, duuuude, I know. He suggests I go to the Mayo Clinic. I agree.

Meanwhile, my primary sent a referral to rheumatology to have me seen at Swedish to confirm chronic fatigue. This is to keep the stupid disability off my back. Swedish rheum doesn’t call me. I ask my primary’s office. Swedish STILL doesn’t call me. I call them, as follows.

“Hi, I was referred to Swedish rheum and I have not been called.”

“Name, serial number, date of birth, length of little toe. Ah, we just received the referral yesterday.”

“Um, I don’t think so. I was referred over a month ago.”

“Uh, oh,” scrabble noises, “Oh, uh, we got a referral in December. We were not taking new patients in December.”

“When did you start taking new patients?”

“Oh, um.”

“When did you start taking new patients?”

“Oh, uh, January. But we only took the ones that called us, because after they call, we then review the notes.”

“So you ignored the referral until I call? How am I supposed to know that?”

“Oh, uh, we will expedite your referral. Maybe even today.”

So THEN I get a message from my primary that they have REFUSED the referral. Great.

Meanwhile I read the cardiologist’s note, which pisses me off. “We will refer you to Mayo Clinic since you have unexplained hypoxia and you think you have PANS.”

I send my primary a very pissed off note saying, could we please phrase this as “a psychiatrist suggested PANS in 2012 and while no one likes this diagnosis, no one else has suggested an overarching diagnosis since that time in spite of her seeing four pulmonologists, neurology, cardiology, infectious disease, four psychiatrists, allergy/asthma, and immunology”. Saying “the patient thinks she has PANS” automatically labels me as crazy and obsessed.

So, it seems I should write a book, about how the medical communities treat patients, including a fellow physician, horribly. Of those doctors, three have treated me with respect and were grown up enough to say, “We don’t know.” The neurologist, the infectious disease doc and the present pulmonologist. All the rest are dismissive and disrespectful. Oh, and the one psychiatrist, but the next one says, “I don’t believe in PANDAS.” I stare at him in disbelief, thinking “they are animals related to raccoons that live in China, you moron”. I did not even know it was controversial until that moment. Holy PANDAS, Batman.

My primary has suggested I write to the Mayo Clinic myself, and I am going to. Because the present people aren’t listening, except my pulmonologist and she is short staffed and looks like death warmed over post call every time I see her.

So it’s all annoying as hell. The cardiologist seemed pretty nice, but damn, he put the same damn rumor down about me self diagnosing. Most of the doctors apparently think I might be a tolerable person if they could just drug me with psych drugs. And from what I have seen, there are many patients who are in this situation.

For the Ragtag Daily Prompt: WAR.

https://pubmed.ncbi.nlm.nih.gov/30724577/

Click to access MECFS_KeyFacts.pdf

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hope for good coming out of isolation

This video is from 2011. I was invited to be a speaker and had ten minutes to present the Mad as Hell Doctor program, talking about single payer healthcare, medicare for all.

If there is a good thing to get from Covid-19, for me it is single payer healthcare. Because doctors and nurses and staff are worn out, sick, quitting, dying. We need people to take out sick appendixes. We need people to work in nursing homes. We need to support our medical people and I am NOT talking about insurance corporations. They are making more profit than ever. Twenty percent of every dollar paid to them or more.

People say, but it’s socialized medicine, to have medicare for all. Well, no. The only socialized medicine in the US currently is the Veterans Administration. No one that I talk to wants to take away Veterans benefits. Or any of the other government programs: medicare, medicaid, active duty military. The oldest, the poorest and disabled and the people defending our country.

But physicians can do a better job if they are not worrying about prior authorization from 500 + companies, each with multiple different insurance contracts, and who can change what they cover at any time. I get emails all the time: we have changed what we cover. Great. Like I have time to read and learn 500+ insurance contracts. I memorize medicare rules and they change too. Medicare for all, one set of rules and then if you ask if something is covered, we will know.

I am not the only physician who wants single payer: Physicians for a National Healthcare Program.

Physicians for a National Health Program

I find this on line: https://www.quora.com/Could-Medicare-or-Medicaid-be-expanded-to-the-general-population-to-create-single-payer-healthcare-Would-it-be-more-efficient-than-an-entirely-new-program?share=1

The answer is yes, yes, yes. And there would be a continuous ongoing battle about what is covered and what isn’t but that already happens. For two reasons: medicine changes continuously as the science changes and there is a vocal strong fringe, which is occasionally correct. I don’t trust the fringe, but then I don’t trust insurance companies, herbal medicine makers or politicians either.

_____________________________

I can’t credit the videographer because I did not know that the video was being taken or that it was posted. I found out when a new patient said she was seeing me because of my video. I had to look it up.

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Covid-19: Good and Bad News

I am writing this on Christmas morning.

The good news is this: National Guard Empties Bedpans and Clips Toenails at Nursing Homes. “In Minnesota, an ambitious initiative is training hundreds of Guard members to become certified nursing assistants and relieve burned-out nursing home workers.” (1) Well, hooray, the National Guard is called out to help, because the nursing homes are out of staff and we aren’t supposed to abuse our elderly. I think this is AMAZING. And the National Guard may learn some things about work and the elderly too. Hoorah and Hooray!

The bad news is a snippet from New York State: Omicron is milder, BUT the exception may be children. (2) Child cases of Covid-19 are going up really fast and hospital admissions of children. ICU work is hard hard hard, but child and infant ICU is even harder. Blessings on the nurses who do this and the physicians too. When I did my pediatrics rotation way back in Richmond, VA, in a tertiary care hospital, I had children who were dying: one with a brain tumor, one with liver cancer, one with Wilm’s disease. Hard work. I chose Family Practice. I have still had pediatric patients die, including an 18 month old where I had taken care of mother through the pregnancy, but not terribly many. Even less in the last ten years since my average patient was about age 70. All of my kids in the last ten years were complicated: one with Down’s, another a leukemia survivor, others. Children can be very medically complicated. I had two adults who had survived infant heart surgery as well. They were set up with UW’s Adults who had Childhood Heart Surgery Clinic, though that is not the correct name. I am pretty happy to have that sort of back up only two hours away. They both had pretty awesome heart murmurs and that midline chest zipper scar. Ouch.

So, why post this on Christmas? If the cases are rising in children, maybe that will inspire some folks to get vaccinated or at least not yell at family who refuse to bring small children to an unvaccinated Christmas gathering. Judging by the posts on the doctor mom facebook group, there is quite a bit of family yelling going on. Stand down, folks, and respect other peoples’ boundaries.

The problem is, if enough children are sick, we run out of beds. And staff. “As of Thursday, there were 1,987 confirmed or suspected pediatric covid-19 patients hospitalized nationally, a 31 percent jump in 10 days, according to a Washington Post analysis.” (3)

Blessings.

1. https://www.nytimes.com/2021/12/22/health/covid-national-guard-nursing-homes.html?action=click&campaign_id=154&emc=edit_cb_20211223&instance_id=48593&module=RelatedLinks&nl=coronavirus-briefing&pgtype=Article®i_id=165651500&segment_id=77808&te=1&user_id=c97a1a8547f511fe3bd45b0806ed713c

2. https://www.nytimes.com/2021/11/23/us/covid-cases-children.html

3. https://www.washingtonpost.com/health/2021/12/24/omicron-children-hospitalizations-us/

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Covid-19: Long Haul

https://www.bbc.com/news/av/world-us-canada-58918869 Some people with Long Haul Covid-19 are having to relearn how to walk and talk.

https://www.bbc.com/news/uk-england-leicestershire-59674203. Patients who were hospitalized are still affected at 5 months and one year after they are released from the hospital. Being female and obese are big risk factors. The article says “Long Covid has the potential to become highly prevalent as a new long-term condition.”

One more:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8146298/ ” While the precise definition of long COVID may be lacking, the most common symptoms reported in many studies are fatigue and dyspnoea that last for months after acute COVID-19. Other persistent symptoms may include cognitive and mental impairments, chest and joint pains, palpitations, myalgia, smell and taste dysfunctions, cough, headache, and gastrointestinal and cardiac issues.”
“One puzzling feature of long COVID is that it affects survivors of COVID-19 at all disease severity. Studies have discovered that long COVID affects even mild-to-moderate cases and younger adults who did not require respiratory support or hospital or intensive care. Patients who were no longer positive for SARS-CoV-2 and discharged from the hospital, as well as outpatients, can also develop long COVID [24,30,31,41,50]. More concerningly, long COVID also targets children, including those who had asymptomatic COVID-19, resulting in symptoms such as dyspnoea, fatigue, myalgia, cognitive impairments, headache, palpitations, and chest pain that last for at least 6 months [51–53].”

And the symptoms? “The most common ongoing symptoms were fatigue, muscle pain, physically slowing down, poor sleep and breathlessness.”

Yes, the same as mine.

My initial evaluation of Long Haul Covid-19 patients will cover three areas:

1. Behavioral Health. Are they having brain fog, feeling slowed, feeling like they can’t think? Is that what happened during the Covid-19 or did the opposite happen? Were they manic/ADHD/OCD etc? What happened in the weeks leading up to getting sick? Any major worries or life trauma? Lose a job, a relationship, someone in the family die? I am looking for a dopamine antibody pattern.

2. Musculoskeletal Chronic Fatigue. What muscles work and which muscles don’t work? If they need to lie in bed for 20 hours a day, both slow and fast twitch muscles are affected. If they are short of breath, they should have pulmonary function tests, including a loaded and unloaded walk test. Are their oxygen saturations dropping? They also need a sleep study. Check for sleep apnea. Any signs of ongoing infection with anything? Teeth, sinuses, ears, throat, lungs, stomach, lower gut, urinary, skin.

3. Musculoskeletal Fibromyalgia. WHEN do their muscles hurt? Is it after eating? Do they fall asleep after they eat or does their blood pressure drop after eating? What diet changes have they made? Are there things they have identified that they can’t eat? Gluten, lactose, meat, sucrose, fructose, nightshades, whatever. I am looking for antibodies to lysogangliosides.

Treatment:

High antibody levels can be lowered somewhat just with “lifestyle changes” aka no drugs.

A. Treat infection if present. Look for strep A with an ASO, since we have an occult one that is in the lungs, not the throat. For fungal infection, even just on the skin, lower blood sugar as much as tolerated. This may mean a ketotic diet.

B. Treat behavioral health with drugs if emergent. If suicidal or really losing it (meaning job/relationships/whatever), then drugs may be needed. But not forever. Avoid benzodiazepines. Check for addictions.

C. Lower antibody levels:
a. Lower stress. Many people will resist this. Counseling highly recommended, ‘cept they are all swamped. Have the person draw the three circles: a day in the present life, their ideal life and then what their body wants. Listen to the body.

b. You can sweat antibodies out: hot baths, hot shower, steam room, sauna, exercise. Daily in the morning, because cortisol rises when we get up, and so levels should be lowered.

c. Is there a stimulant that works for this person to calm them down? Or an antidepressant if they are slowed instead of sped up. The relatives of dopamine that work for ME are coffee caffeine and terbutaline. Ones that do NOT work for me include albuterol and tea caffeine. Ones that I have not tried include theophylline, that new relative of albuterol and ADHD meds like adderall. This will be individual to the person because we all make different antibodies. We are looking for a drug that displaces the dopamine antibodies. For people who are slowed or have brain fog, the stimulants may not work. I would try the SSRI antidepressants first, like sertraline and citalopram, unless the patient tells me they don’t work or make them anxious. I would screen for PTSD. For high PTSD scores and high ACE scores, I would use the old tricyclics, mirtazapine (which is NOT a benzodiazepine), wellbutrin or trazodone. Again, avoid benzodiazepines. Also check how much alcohol and marijuana are on board, because those are definitely going to make brain fog worse. The functional medicine people are treating mystery patients with hyperbaric oxygen chambers and I suspect that this works for the people with blocker tubulin antibodies.

d. Muscle pain/fibromyalgia symptoms. Avoid opioids, they will only work temporarily and may addict. Avoid muscle relaxants, they will only work temporarily. Again, the tricyclics may help. The newer antiseizure drugs that are indicated for fibromyalgia are possibilities, though as an “old” doctor I am conservative about “new” drugs. Gabapentin, pregabalin, and if the person is sped up, antiseizure medicines that are used for mania. GENTLE exercise. The line between me having a good day today and overdoing is knife thin. On the overdoing days I go to bed at 5 pm. I went to sleep at 5 pm yesterday and 6:30 last night. I sang for church last night and even though I’d driven myself there, one of the quartet offered to drive me home. “Do I look that grey?” I asked. “Yes.” he said. I turn grey from fatigue and it can be sudden. Right now it’s after my second meal. If I am active, I will fall asleep after lunch if I can. If I go really light on lunch, I crash right after dinner. And remember, I am one of the lucky people who only have fast twitch muscles affected, not fast and slow twitch.

I am adding this to yesterday’s Ragtag Daily Prompt: hopeful.

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Covid-19: masks work, we figured that out YEARS ago

I was thinking about masks and the whole “masks don’t work” or “masks are unproven*” thing. That is complete and utter crap. We proved masks work YEARS ago.

If they don’t work, do you mind if your surgeon don’t wear one? What about your nurse with a cough when you are in the ICU? I think we have proved quite definitively in the operating room that masks work.

Also, your family doc and OBgyn ain’t gonna NOT wear a mask when delivering baby because it can be REALLY SPLASHY. And some patients who are delivering a baby have hepatitis B or HIV or hepatitis C or whatever. WE DO NOT WANT TO CATCH IT SO WE WEAR MASKS. MASKS WORK.

And take tuberculosis. Tuberculosis bacillus is tiny and can be air borne, if you have active tuberculosis and cough. We use reverse flow rooms in the hospital with an airlock: a door to a small entry room, that has to close before you enter the inner patient room. And the air is slightly lower pressure so that air comes in from the airlock but doesn’t flow out. All the air out of the room is filtered to catch and kill the tuberculosis bacillus. We go in the airlock and put on nearly full gear: gown, gloves, mask, hair covers, shoe covers. When we come out, we take it all off in the airlock. We also keep a stethoscope in the room so that we don’t carry infection from patient to patient.

So the whole anti mask thing seems categorically insane to me.

Like, didn’t we figure out masks work back before the civil war? Or thereabouts. No, maybe later than that. Without masks and gloves we had all the women with post baby fever, who died like flies and most people died of infection after surgery. Until that coke addict at Johns Hopkins made people wear clean clothes and wash their damn hands before each surgery and wear gloves. Suddenly people survived post surgery at a much higher rate. Everyone came to train with him to imitate him. By 1897 everyone was wearing gloves to prevent infection. And so a brilliant coke addict invented medical residency, which is why residents are not allowed to sleep. We’ve gotten over that a bit.

Anyhow: masks work. Think, people, think.

*Usually the unnews qualifies this as “masks are not PROVEN to work with Covid-19”. What, you want a ten year clinical trial first? Are you crazy? And the resounding answer is “YES! We are crazy!”

For the Ragtag Daily Prompt: December. Because everyone should have figured out masks by now.