Category Archives: mental health

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Travel risks

The President is withdrawing the United States from the World Health Organization. https://www.whitehouse.gov/presidential-actions/2025/01/withdrawing-the-united-states-from-the-worldhealth-organization/

Here is the link to write to the President: https://www.45office.com/contact/

I am writing daily, just not for the Ragtag Daily Prompt. Here is my short note today:

Dear President Trump: I strongly disagree with withdrawing the United States from the World Health Organization. One function of that organization is travel clinics. If a person is traveling to another country, they can find out what illnesses are present there and get immunizations and advice to avoid getting ill. This also helps physicians treat people who have returned from another country. The physician can contact a state health department which is in turn connected to the World Health Organization. This is a foolish, dramatic and unscientific decision on your part. I suggest that you reverse it immediately or resign as President.

________________

The question I have, is he closing the borders to United States citizens too? Without the travel clinics, who get information about each country from the World Health Organization, aren’t even our own state department employees at higher risk for illness? My son was an exchange student to southern Thailand. At the time he went, there was Japanese encephalitis. He was there two years after the tsunami. He got vaccinated for Japanese encephalitis before he went and he also took medicine to avoid malaria. So, are we not going to send or accept any more exchange students?

I strongly disagree with the decision to leave the World Health Organization and our country is on the verge of crazy.

For the Ragtag Daily Prompt: verge.

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Intimacy

What IS intimacy? And what is love? And are they the same thing? Do you have to be intimate to love someone? Not meaning sex, but what level of intimacy is “normal” and “appropriate”?

I am thinking of my mother. When I was just starting college, she started talking to me about my father and about his drinking. I became more and more uncomfortable and finally asked her to find a counselor or someone other than me. The thing is, she refused to DO anything about his drinking and in fact, covered it up. The two of them would scream at each other at 2 am and fight when I was in high school. It would wake me up and I would think, I wish they wouldn’t, because I have school tomorrow. But I certainly didn’t go say anything because then they would have screamed at me. And as I got older, I wondered if my mother was drinking heavily too. Because why would she argue with someone drunk at 2 am, that makes no sense. Unless she either was drunk or loved to argue or both.

It is clear that she was drinking heavily at that time from her journals. Over and over she writes, I drank too much last night. Hard to blame her for not intervening with my father if she is drunk too. But she was using him as her cover up. Her family blamed him. My grandmother, her mother, didn’t blame him. She loved them both.

When we had guests, my mother would turn on the charm. She could mesmerize a room and entertain people with stories. My sister and I and others would be the butt of the stories. My father too. After the guest left, she would often talk about them. Analyze them. Talk about their faults and weaknesses. I was fascinated but a bit horrified too. She seemed to like these people so much and to charm them and invite them back, but was talking about them behind their backs. Ick.

So intimacy interests me. I wonder how to do it “right”. Maybe right is not the best word. How to do it “functionally”. I really don’t know what normal is, my maternal family certainly did not model healthy intimacy. My generation still gossips about each other. I quit that at age 19 and refused to be part of it. I don’t think anyone saw my rebellion except my maternal grandmother. She did not say a word but I knew that I had her respect. She did not play the family game with me.

I don’t think that gossip and triangulation are a good form of intimacy or love. Person A talks to person C about person B. Word gets around and sometimes it is person D that says something to person B and person B gets upset when they realize where this came from. And how twisted and one sided the story is. And aren’t we seeing this play out on a national level? All these people saying that THEY KNOW the status of the President’s memory. I don’t. I can’t judge it from a debate. And frankly, if we are going to do a psychiatric evaluation of one, I think we have to do BOTH. Stop following stupid rumors. Why not require a neuropsychiatric evaluation on every candidate for President and Senate and House of Representatives and the Supreme Court. And make them public. That would cause some chaos, wouldn’t it? And how do you decide who is “sane” enough to govern?

I think that gossip and triangulation is a dysfunctional form of intimacy. People feel closer when someone is whispering a secret to them. I don’t think it’s healthy. It might be normal for our culture, though. Normal does not mean healthy, after all. What do you think?

This election is like a bad hallucination. Why do we accept candidates that behave badly? Are we so addicted to television and movie drama that we want it to happen in our government? I don’t. How about you?

For the Ragtag Daily Prompt: hallucination.

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Staying the course

Have you ever started talking to someone, only to find out that they throw amazing accusations and lies at you? I have had a patient say “You are FORCING me to use heroin.” It’s a bit disconcerting.

Imagine this in a debate. I can leave the room and end things in clinic. I can ignore family members that tell made up stories about me over and over. They want to believe what they want to believe. They don’t fact check. Aren’t you glad I don’t do that with people in clinic? Make stuff up? I don’t want a doctor who does that nor a president.

I don’t find it “presidential” to spend an hour and a half snarling lies, false blame and accusations. That is not leadership.

I am not voting for the biggest liar on the block.

For the Ragtag Daily Prompt: serenity.

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Walk with rabbits

Some days I can’t chuckle
when the news rolls in
my heart could buckle
shootings again

US gun habits
What’s up doc? Dagnabbit.

Shootings on the year of the rabbit
dancers dead as they celebrate
Why are guns such a habit?
I refuse to fill my heart with hate

Gun sales stab it
Year of the rabbit

Forgive but do not reconcile
let my resolve not buckle
mental health takes a while
let no demented chuckle

Fearful gun habits
online snared like rabbits

They argue they must defend their homes
daughter teacher on the line
fearful males online alone
think that guns will make them fine

Fear is a habit
Stop being rabbits

Leave your basement
Help another
Walk the pavement
Earth as mother

Make it a habit
To walk out with rabbits

_______________________

For the Ragtag Daily Prompt: chuckle.

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how to protect codgers

A friend calls me yesterday, complaining that the new Covid-19 vaccine doesn’t prevent infection nearly enough for him to want to get it. He is in his 70s and says darn it, he’d still have a 60% chance of getting infected.

I thought about it and wrote back this morning:

Re the new vaccine the POINT is NOT to prevent infection, though it lessens it in codgers like me and you.

The point is that the vaccinated younger people shed a s–tload less virus if they get it, because their immune system kills it fast. This reduces the amount of circulating virus so that the codgers stop dying like flies. Also the codgers get less sick if their immune system recognizes B4 and B5.

Got it? Get the vaccine.

I am waiting for the top ten causes of death for 2021 to come out. Over one million US people have died of Covid-19. In 2020, there were between 300-400,000 deaths from Covid. That means that we lost 600-700,000 in 2021. If we lost close to 700,000 people, then Covid-19 would beat out heart disease as the number one cause of death in the US. When did that last happen? During the 1918-1920 influenza, the “Spanish” flu that has been traced to a chicken farm in the US midwest.

Here is a provisional and not final list: https://www.cdc.gov/nchs/data/health_policy/provisional-leading-causes-of-death-for-2021.pdf. Hmmm. The numbers are not adding up unless a lot of US people died of Covid-19 in early 2022. And cancer is higher than it’s ever been and creeping up on heart disease. But these are not the final numbers, sigh.

Here is a fascinating chart: https://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf. If you scroll to the end, the top two causes of death in 1900 were pneumonia first and tuberculosis. Heart was fourth. Heart rises to first in 1910 but then pneumonia is back at the top in 1918-1920. I think that the heart has been number one ever since, in the US. World top ten is not the same.

This is not the first pandemic and it won’t be the last. It is horrible. I think that everyone is doing the best they can, though some responses seem saner than others. Remember the old doctor joke about what to do in a code (when someone’s heart has stopped). First: check your own pulse. It’s a corollary that if the patient is dead, you can try to bring them back, but you can’t make them more dead. Also, my latest Advanced Cardiac Life Support class, on line, told me that sometimes I do not have to do cardiac life support. Their example was a decapitated patient. Really? Ouch, doctor humor. But truly, if you are freaking out or want to scream at someone or feel like the world is nuts and you have to do something, first check your own pulse. Slow it down. Breath in four and out four. I can drop my pulse from 101 to 71 in 20 seconds, just by slowing my breathing. You can learn to too.

My recommendation is that if you are due for the booster, get it. And thank you for protecting me and my friend and the other codgers.

No, it is not snowing here yet. But codger seems to be a word for an old GUY. Humph. Would a grumpy hummingbird be a grummer? What is a female codger? I am using codger for any gender, to heck with it.

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what would YOU choose?

Here is a story of a choice about an abortion, a theraputic abortion, where a mother has to make a difficult choice. I have seen Family Medicine patients since 1991, so this will not identify a particular person. No HIPAA problem.

I see a new patient in clinic, a woman, who already has children. She has back pain. All is routine until she says, “Sometimes my leg goes numb from the knee down.” I stop. This is NOT normal. “Completely numb?” I say. “Not patchy?” “Yes.” “How often?” I ask. She shrugs. “Not very.” “If it happens again, call me and I want to see you right away.”

Why? This is unusual because most numbness follows dermatomes if it is from back pain. The dermatomes on the skin wrap from the back down the leg all the way to the toes. When someone describes numbness or the pain of shingles in that distribution, we know which nerve is affected. Numbness from the knee down can come from diabetes and other causes, but it is not on one side and it doesn’t come and go. So the unusual stands out for me.

“Anything else weird?”

“I had vision problems in my last pregnancy. They sent me to specialists, even a neuro opthamologist. He couldn’t find anything.”

“Ok.” I shrug. We move on.

She calls two days later. “Both legs are numb from the knee down.”

“Come in today,” I say.

Both legs ARE numb from the knee down. She also can’t lift her feet. The muscles from the knees down are weak. I get neurology on the phone. “MRI her from the top of her head to the base of her spine.” I call the hospital and set it up. That day.

She has seven brain lesions suspicious for multiple sclerosis. She did have an MRI in the previous pregnancy, which was negative. I do not remember how old the child was, 2-4 years or more when I saw mother.

I call her back in for results, we talk about specialists, and I call a neurologist in the nearest big city, three hours by car from where she lives. We start medications and my patient is scheduled.

She has multiple sclerosis. The flare improves. The visual symptoms were MS in the previous pregnancy, but it was not yet visible on brain MRI.

Then she gets pregnant again. Her symptoms immediately flare. She comes to me and I call the neurologist.

The symptoms are not a little worse. Much worse. “I suggest she terminate the pregnancy.”

My patient is horrified. Until the neurologist’s next words. “She needs to terminate if she wants to be able to walk for the children she has.”

My patient chooses an abortion, to terminate the pregnancy. Because she has a bad version of MS*, she remembers the symptoms in the last pregnancy, she is young, she is clearly progressing and she wants to take care of the children she already has.

What would YOU choose? For yourself, for your sister, for your wife. If you are male, do you have any right to make that choice? Now picture yourself pregnant with that choice. And thank you for reading this.

*Addendum: present evidence says that multiple sclerosis does NOT worsen with pregnancy. However, another illness, NMO (neuromyelitis optica) instead tends to become more active in pregnancy. It previously was lumped in with MS until the antibodies (anti-NMO) were identified and it was realized it’s a different subtype of demyelination disease, with its own treatment options. Medicine changes over time and the woman, the neurologist and I were working with the information available at that time.

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stranded mermaid, cilia and tubulin

I took this photograph last summer at North Beach. I thought she looks like a stranded mermaid, thrown up on shore. I couldn’t move her, she was twice my length. The rock attachment had come too, up from our sea beds.

Happy solstice. Today marks the one year day from when I realized that I was having my fourth round of pneumonia, with hypoxia, agitation, fast twitch muscle dysfuntion and felt sick as could be. I am way better but not well. That is, I still need oxygen to play flute, to sing, to do heavy exercise and to carry anything heavy. Which is WAY better then having to wear oxygen all the time. Today I find a connection between the lungs and the brain, in quanta magazine. This video talks about a new found connection between cilia and the brain. We were taught that cilia and flagella are for locomotion, powered by tubulin. However, this shows that cilia behave like neurons and there is a connection. Since my peculiar illness seems to involve cilia dysfunction in my muscles and lungs, so that I get pneumonia, and the brain, because I am wired when it hits, this is a fascinating connection. If neurons developed from cilia, the dual illness makes a lot more sense. Hooray for quantum mechanics! We use it in medicine every single day.

https://www.quantamagazine.org/before-brains-mechanics-may-have-ruled-animal-behavior-20220316?mc_cid=80d950ddd6&mc_eid=5faa14000f

Happy solstice! Here comes the sun!

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wearing sunglasses in the rain

Trigger warning: this is about dementia. I wrote this over ten years ago.

wearing sunglasses in the rain

I am weeping for you both

you have cared for her
for better or worse, for richer or poorer, in sickness and health

and she has lost her memory

you told me on the phone
that it’s not that bad

you say it again in the room

I knew before I saw her
that it was bad, very bad, much worse
she is only 60

she becomes agitated when we try to weigh her
old style doctor’s scale
frightens her to try to step up.
gentle caregiver that you have hired
pushes her, until I say stop, stop, stop
her weight does not matter

shuffling gait
she is frightened to be in a new place
I ask her questions gently
she does not want to sit in the chair in the exam room
“No!” she says “No!”
I leave the room until she’s calmer

when I return
I give her choices
“Shall I examine you first with my stethoscope
or shall I talk to your husband?”
I choose for her, the latter
she relaxes, a little
later, I tell her each step before I do it
she is slightly tense when I lay the stethoscope
on her thin shoulders, but she doesn’t fight

she tenses as I ask her husband questions
about the memory loss
ten years now, a steady course
I ask him what he understands about the prognosis
he shifts uncomfortably
and I ask her if she would like to wait in the waiting room
while I talk to him
Firm and clear: “Yes, I would.”

She is not in the room now
he says that she is not too bad
the picture comes slowly in to focus
mild memory loss, is what he thinks

there are three stages of memory loss, I say
mild, the short fibers, where short term memory is affected
we forget what someone just said
moderate, the medium axons
we forget the recipe that we’ve know for 50 years
we forget how to do math
we forget names and how to get to the store
we forget how to operate the car
severe, the long axons
executive function
we do not initiate things
we forget to get dressed
we forget how to speak
we forget our potty training

his eyes grow sadder and sadder

at last, we return to being a baby
we forget everything
at last, we remember the womb
we no longer want to eat

is she forgetting to eat?

he is not ready to answer

as we leave the room
he says that she is not sleeping well
she seems to be awake at night
eyes closed
but her fingers are moving, as in play
he doesn’t speak to her
he needs to sleep and thinks she should too

should he give her a sleeping pill?

maybe she is happy, I say
maybe in bed in the dark
you are there and it is safe
no one is making her get dressed
no one is making her bathe
maybe that is where she wants to be awake
I would not give her a sleeping pill

the dogs are in the room
he says
and the tv is on just a little
maybe she is happy

he is wearing sun glasses
as they cajole and help her in to the van

he is wearing sun glasses
though it is overcast, low clouds and raining

sometimes it is so hard
to say what I see
to try to say the truth

sometimes the truth is not gentle
but sometimes the truth is love

I am weeping for you both

written 2010

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Cognitive behavioral therapy

Dr. Aaron Beck, father of cognitive behavioral therapy, died this week, November 2021, at age 100.

Oddly enough, the best explanations of cognitive behavioral therapy that I’ve read is on a writing website. It talks about writing down all of the horrible thoughts and then going back and writing counter thoughts. Psychologists have been talking at me at medical conferences for years about cognitive behavioral therapy, but they never explained it. They said we could do it in clinic. I thought cynically that maybe I could if I knew what the hell it was.

And the explanation by the author is oddly similar to what I think of as the angel and devil on my shoulders. It turns out that I do do it in clinic.

When I react to some event, I let the devil out first. It has a fit about whatever is happening, writes poems, is reactive, paranoid and full of anger and grief. It often imagines over the top terrible things happening to the person or people that did whatever it is. Then the angel wakes up and says, wait. What are you saying? What you are imagining and cursing that person with is WAY worse then what they did. The angel writes the poems of forgiveness.

So I have been doing a homemade form of cognitive behavioral therapy.

However, I would say that it can be overused. We need to listen to patients carefully. If they are in an abusive relationship, it should not be papered over with cognitive behavioral therapy. A friend and I have been comparing terrible childhoods. His involved being beaten without reason.

I said recently that what people hit with in my family is words. They make grief and fear into stories, funny stories, that make people laugh. Shame and humiliation and reliving the feelings. I said that I am reactive and pay close attention to words. But I have reason, back to age 2. I said that books are my refuge because the words are not about me, they don’t shame me, they do not humiliate me, and if I read a book twice, it has the same words. Home, love and safe.

In my maternal family, if I said that I was not comfortable with a comment, I was told that I took things too seriously, that I have no sense of humor, that I can’t take a joke. Gaslight and then dismiss any objection. That is how one side of my family loves. I do not like it. Unsurprisingly, they do not love me, or at least I do not feel loved.

And my friend said, your family, your childhood, was worse than mine.

One of my talents in clinic is that I can listen to insane family stories. I can listen because my family is insane. They are cruel. At least, it feels like cruelty and horror to me. I didn’t ever try to find out if a family story is true. I listen and then say, yes. I think it is appropriate for you to feel angry/sad/horrified/appalled/scared/hurt/whatever.

Somehow that listening and validation is huge. I have people come in and say, “I NEED AN ANTIDEPRESSANT.” They want to supress the feelings. So I had time in my clinic: why do you need an antidepressant? Tell me the story. Fill me in. What are you feeling and why?

And more than half the time after the story, after validation, I ask, “Do you need an antidepressant?”

The person thinks. “No. I don’t think so. Let me think about it. I feel better.”

“Ok. Do you want to schedule a follow up?”

Half do. Half say: “No, let me wait and see. I will if I need it.”

Mostly they don’t need it. They have emptied out the awful feelings in the exam room and they aren’t so awful after all. I say that it sounds like a pretty normal response and I would feel that way too. Because I would. Once the feelings, the monstrous feelings, are in the light of day, they relax and evaporate, dissipate like mist, fly home to the Beloved. Goodbye, dark feelings. You are appropriate and you are loved.

Blessings, Dr. Beck, and thank you.

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released like stars

I have had strep A sepsis and pneumonia twice. It was terrifying and I ended up having to take care of myself. I would be dead if I was not a physician.

Not to be named obscure website helped to sustain me, because it was a place I could go while I was alone, terrified and very very ill. The bout in 2014 took me out of clinic for six months and then I was barely able to work seeing half my usual number of patients. My local hospital refused to help me, but other people did. I am deeply deeply grateful to the people who did help me, including people on everything2.com that I have never met.

I wrote this in June 2014.

released like stars

________________

My sister used to tell me

β€œEverything2 is like a brain.

That’s what attracted me.

All the nodes, like neurons

Connected to each other more and more.”

Or something like that.


Isn’t it annoying?

Now that I’ve taken that memory out

Dusted it off

Embellished it

Who knows what she really said


Flashes of light now

And some where I blank out entirely

For just a moment

Only when I’ve eaten

I’m still avoiding carbs


Could be absence seizures

But she said seizures hurt

These do not hurt

And are accompanied by muscle twitches

Or muscles rolling gently across my frame


I am scared at first

Because I think they are neurons

Bursting into brain flame

And burning out

Brief candles


But I don’t think that’s right either

I think it is plaques

Deposits of antibody

Small pushpins in the wrong place

Being released like stars