Category Archives: rural doctor

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Top ten causes of death: US 2020

Top ten causes of death US 2020, according to JAMA, here.

Total deaths: 3,358.814
Contrast total deaths in 2019, at 2,854,838. That number had been on a very slow rise since 2015 (2,712,630) to 2019 (2,854,838). That increase over four years is 142,208 people. Then the death rate suddenly jumps 503,976 people in one year. Ouch. I cannot say that I understand vaccine refusal.

1. Coronary artery disease: 690,882
Heart disease still wins. And it went up 4.8%. It is suspected that people were afraid to go to doctors and hospitals. I saw one man early on in the pandemic for “constipation”. He had acute appendicitis. I sent him to the ER and his appendix was removed that day. He thanked me for seeing him in person. Might have missed that one over zoom.

2. Cancer deaths: 598,932
This is cancer deaths, not all of the cancers.

3. Covid-19: 345,342
I have had various people complain that covid-19 is listed as the cause of death when the person has a lot of other problems: heart disease, cancer, heart failure. The death certificate allows for more than one cause but we are supposed to list the final straw first. I cannot list old age, for example. I have to list: renal failure (kidneys stopped working) due to anorexia (stopped eating) due to dementia. That patient was 104 and had had dementia for years. But dementia is not listed as the final cause. So if the person is 92, in a nursing home for dementia and congestive heart failure, gets covid-19 and dies, covid-19 is listed first, and then the others.

4. Unintentional injuries: 192,176
Accidents went up, not down, which is interesting since lots of people were not in their cars. However, remember that the top of the list for unintentional injuries is overdose death, more by legal than illicit drugs. If there is no note, it’s considered unintentional. Well, unless there is a really high blood level of opioids and benzos and alcohol. Then it becomes intentional. They do not always check, especially if the person is elderly. The number rose 11.1%, which seems like a lot of people.

5. Stroke: 159,050
This rose too.

6. Chronic lower respiratory diseases: 151,637
This went down a little. This is mostly COPD and emphysema. So why would it go down? Well, I think bad lung disease people were dying of covid-19, right?

7. Alzheimer’s: 133,182
This seems to belie me putting renal failure due to anorexia due to Alzheimer’s. I think they actually read the forms and would put that as Alzheimer’s rather than renal failure, because it is not chronic renal disease.

8. Diabetes: 101,106
This rose too. 15.4%, again, probably partly because people avoided going to clinic visits. Also perhaps some stress eating. Carbohydrate comfort.

9. Influenza and pneumonia: 53,495
So this went up too in spite of a lot less influenza. Other pneumonias, presumably.

10. Kidney disease: 52,260
This went up.

And what fell out of the top ten, to be replaced by covid-19?

11. Suicide: 44,834
This actually went down a little. What will it do in 2021?

So what will 2021 look like? I don’t know. It depends what the variants of covid-19 do, depends on what sort of influenza year we have, depends on whether we are open or closed, depends if we bloody well help the rest of the world get vaccinated so that there is not a huge continuing wave of variants.

Today the Johns Hopkins covid-19 map says that deaths in the US stand at 608,818 from covid-19. If we subtract the 2020 covid-19 deaths, we stand at 263,495 deaths from covid-19 so far this year. Will we have more deaths in the US from covid-19 than in 2020? It is looking like yes, unless more people get immunized fast.

Take care.

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Oxygen testing

“If oxygen might help with chronic fatigue, as it has helped you,” a friend asks, “how do I get on oxygen?”

Complicated answer.

First of all, one of the things that is not clear, is what recovery looks like. I think I’ve had low grade chronic fatigue for the last 7 years compared to my “normal”. Now, will I get off oxygen? I don’t know. I am hoping for September but it may be that 7 years of low grade hypoxia means I have lung damage and no, I won’t get totally off oxygen.

They have apparently recently made the guidelines for oxygen more stringent. I sort of missed that update, even though I just recertified in Advanced Cardiac Life Support. You now have to have an oxygen saturation that goes to 87% or below. It used to be 88.

Now, you can test this at home with a pulse oximeter. In 2005 after the influenza, I held my saturations but my heart rate would go up to 135. Which means that I walked across the room very very slowly because a heart rate of 135 sustained does not feel good at all. Normal is 70-100 beats per minute. You can measure pulse with just a second hand, number of beats in a minute. For oxygen saturation, you need the pulse ox and it will measure both heart rate and oxygen saturation.

So: measure pulse and saturation at rest first. Write them down.
Then walk. I usually send patients up and down the hall three times then sit them down and watch the pulse ox. In some, the heart rate jumps up. If it’s over 100 and they are getting over pneumonia, I don’t want them back at work until it is staying under 100. Or if sitting they are at a pulse of 60 and then walking it’s 95, well, I think that person needs to convalesce for a while yet. They can test at home.

As the heart rate returns to the baseline, the oxygen level will often start to drop. Does it drop to 87? Describe the test to the doctor and make sure the respiratory technician does it that way and also they should do pulmonary function tests. Mine were not normal.

Now, what if the oxygen doesn’t drop to 87? We are not done yet. What does the person do for work or do they have a toddler? If they have a toddler do the same test carrying the toddler: they sit down, exhausted and grey and this time the oxygen level drops below 87. If they do not have a toddler, do the test with two bags of groceries. Or four bricks.

When I did the formal test, the respiratory therapist said, “Let’s have you put your things down so you don’t have to carry so much.”

“I’d rather not.” I said, “I want to be able to walk on the beach, so I need the two small oxygen tanks, my bird book, camera, binoculars and something to eat.”

“Oh, ok,” she said.

So I did the test with two full tanks of oxygen, small ones, and my bird book and etc. I dropped like a rock loaded. I think I would have dropped not loaded but perhaps not as definitively. Still hurts to carry anything, even one tank of oxygen.

We are making a mistake medically when we test people without having them carry the groceries, the toddler, the oxygen tank. My father’s concentrator is pre 2013. It weighs nearly 30 pounds. Now they make ones that weight 5 pounds. Huge massive difference.

Good luck.

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Anomiidae

Walking the beach with a friend a couple of mornings ago, I keep finding shells with a dark marking in the center of the interior and nice shiny interior. Then I find a shell with the other half attached. The other half has a hole in it.

I look it up. This site comes up: http://www.bily.com/pnwsc/web-content/Northwest%20Shells.html. Wow. We filter through it and the shell is in the family Anomiidae. Specifically Pododesmus macrochisma, aka Green False Jingle. It attaches to rocks or other jingles or whatever through the hole. Then it disguises itself. The outside of the shells I found was diverse, some with barnacles. I found a young one, pink, and the radial ridges are visible on the shell.

Cool! Next I tried to identify the two different kinds of chitons. Uh-oh. There are LOTS of chitons. I run out of air very quickly. I will save the chitons for another day. I also returned two sea cucumbers to the sea. The second one scrunches up when I pick her up with a piece of seaweed. When I put the second one in the water, she relaxes. The first one was probably already dead.

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Letter to a younger friend

After my mother died I really struggled, partly because I was in the midst of a divorce and felt like a massive failure. I did not like myself. But I kept thinking about my mother and how much she hid: and eventually I thought, you know, I love all of my mother. Even the stuff she hid. If she is lovable then so am I.

What is lovable in your parent? And would you miss her/him if she/he were truly gone?

That is the hard thing for me, that I couldn’t think about that until she was dead. With my sister, I thought about it before she died and changed how I behaved and let her know when I disagreed with her. Even though she had cancer.

Isn’t the greatest gift we can give each other loving honesty? I love you and I disagree with you and I am not going to do what you want just because you (are my mother/are my father/have cancer/have emphysema/want it/are dying). Isn’t the greatest gift to be ourselves and take the flack for it?

Cucumber love is a poem I wrote more then ten years ago about dropping the exoskeleton that we wear for society’s and our family’s approval. It takes courage. You can drop a little piece at a time and let them get used to it. And yes, some people may reject you for good. That is their choice. But you have to ask yourself then, did they ever really love you or did they only love to control you?

Cucumber love

They say they love you
And they do

Sort of

One day you find yourself
Wearing a construct
An exoskeleton
Awkward
You can move
See out

You built it slowly over years
Because that’s what you were told to do
You wanted to be loved
It made you feel safe

There is praise
Or at least pressure to keep it on
You may not have known it was there
And slowly begin to feel
Who you really are
Awaken to the shell

One day you slip out

They are still saying how much they love you
To the empty construct

You watch bemused
For a while

You say “That isn’t me.”
“Of course it is,” they say

“I’m over here,” you say

Shock and outrage
“That’s not you!
You’ve changed, you’re depressed
Confused, manic, gone out of your mind!”
Off the deep end

You might even go back in to
the construct for a little while

But now you’ve tasted freedom
You won’t be able to stand it for long
You will be out soon

Some people will see you as you really are

Some people will tell you they still love you
But as they say it to the construct
They act as if you’re still wearing it
They still think you love cucumbers
Though you ate that dish once to be polite
They hold the construct in their minds
Even after you’ve destroyed it
And behave the same as they ever did

As you walk away
You will wonder who they loved

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home

We walked the beach on Marrowstone Island yesterday. It’s amazing how different the rocks and shellfish are there compared to North Beach. We are looking for agates, but I got interested in some of the shellfish. My zoology is pretty out of date, but you can find so much on the internet. Then it becomes overwhelming. I look up one creature and find that there are twenty species and can I figure out which one? Sometimes I think so and sometimes I don’t!

I like this shell. The original owner is gone and then barnacles lived there and a seaweed is attached. I am sure there are all sorts of microscopic critters too. I have my microscope and will start looking at the tiny creatures too. Wonderful.

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I don’t think I realized what I had gotten myself into, but it seemed like the potential for fun and insanity were there in equal parts

sometimes you know things
without knowing

sometimes you no things
without noing

sometimes you know things
without noing

sometimes you no things
without knowing

sometimes you koanow things
without knowing

sometimes you no things
without koanowing

sometimes you koanow
without koanowing

sometimes you koanow

snow

also published on another site today.

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He just left his body

This is about memory loss.

One of my patients eventually had to have her husband admitted to memory care. He was falling, he was angry, he outweighed her by 50 pounds and he was incontinent. When he fell, she could not get him up.

She went to our hospital Grief Group and came to see me, angry.

“They said he’s still alive!” she snarls. “I got mad and said, no, my husband is gone! He just left his body!”

“I’m so sorry.” I say. “I am sorry that they don’t understand.”

“I’m selling his stuff.” she says. “I don’t have any use for Ham Radio equipment. And HE doesn’t EITHER, now.”

She stomps out. I am sure she cried too.

That is how I think of Alzheimer’s. Neurons burning out from the present to the past. When the person can no longer talk, they are close. Then they are in the womb and stop eating.

Let them go, let them go, god bless them. Where ever they may be. You may search the wide world over but your memory person is free….

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heatwave tricks

I went to high school in Alexandria, Virginia (Remember the Titans) and we had no air conditioning. I had the upstairs bedroom in front of the house. We were on the road that had the bridge over the train tracks, so we got every ambulance, fire truck and police car sirening from one part of town to the other. b

I live on a “busy” street. When the realtor warned me it was “busy”, I thought, well, not like Alexandria. No gun shots in the house a block over, at least not often. I used to hear the helicoptors landing at the hospital four blocks away, but now that I am not on call, my brain dismisses that as a “not worrisome” noise.

So here are my tricks to stay cool.

  1. Get a bandana or headband wet with cold water. Wrap it around your head. Keep wetting it as needed.
  2. If you are going outside, put a hat over the bandana or headband. If it is a straw hat, you can wet it too. Ditto wool.
  3. Stick your feet in cold water.
  4. Fountains make sounds that make you feel cooler. Find a website with a stream or water sounds. Let it play.
  5. Drink lots of water.
  6. Salt. Now, if you have high blood pressure or heart disease or congestive heart failure, be really careful. My symptom of being too low in salt is feeling nauseated and a bit off and woozy. Those are professional doctor terms, ok? I bought 5 kinds of chips yesterday, beer, seltzer (no sugar) and ice.
  7. Do NOT drink sodas to cool off. Most sodas have salt hidden under the sugar. Screw up your hypertension and the congestive heart disease. Oh, and kidney disease and some liver things. Hey, talk to your doctor. They will say “Do not drink sodas. They are the EVIL dwelling on earth.” Well, ok, your doctor might not say the second sentence. I said stuff like that.
  8. Get ice, put it in a cooler, and put in water, maybe beer if you are healthy enough, (go light on the beer. Max seven drinks weekly for women, fourteen for men, and no saving it up for the weekend. The recommendations are different in the UK and different again in Europe. Who is right? Science is a moving target. It is never DONE. Dang ol science. Just give us the stupid finished book so we can stop arguing about it all…. heh. The truth is, we’d argue about something else.) go light on juice (because sugar), cut the juice in half with seltzer or better yet just drink the seltzer. Now, seltzer has salt again, so all those people who has to watch salt intake… oh, shoot, that is everyone. I drank one beer yesterday and one seltzer and a lot of water and in the morning tea.
  9. Consider sleeping outside. It’s cooler here once it cools off! Alexandria, Virginia didn’t cool off. It would be 98% humidity and 98 degrees. So HOW did I sleep in that?
  10. Take a wet washcloth to bed. Wipe down your arms and face. Get your hair wet right before bed if you need to. Put a towel on your pillow. That, plus a fan blowing over me from the open window, and I could sleep, even in 99 degree weather with 98% humidity.
  11. Water animals, plants and don’t forget your trees. I’ve been watering the trees in the early morning and the lichen on the trunks turns BRIGHT GREEN when I do. Happy lichen. I am watering the leaves of everything in the garden in the early morning, to try to help the plants stay cool. Evaporation helps them too.
  12. Take heat stroke seriously. If someone with you stops making sense, then think about an ambulance and do not let them drive. If the core temperature gets too high, people can die, and they are too goofy to drink water. It also can be damn hard to put an iv into someone dehydrated so call early rather than late. Take care!
  13. Curtains. Shut the curtains to the east in the morning. Open them and shut the ones to the south at noon. Open them and shut the ones to the west in the afternoon.

Ok, so I put some rocks in the Beatnik bathtub fountain so that if a mouse falls in, it has somewhere to climb out. Then I went to QFC looking for a sprinkler. I would be hobbling through the sprinkler, but it’s still very cooling. They were out. However, I found fish. Squirt fish. They promptly went in the fountain.

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Judgement

Why are the roses caged, you ask? What did they do? Nothing, they are being protected. I found that rose and transplanted it years ago, but our deer eat the buds every year. This is the first time that it has bloomed in the 21 years I have lived in this hours. Isn’t it beautiful?

I am listening to this:

I wrote this poem today. This is one of the poems where I have no idea where it will go when I start writing it. I start writing about judgement and it never ever goes where I expect. The poems go where I want to go in my deepest heart, in my soul. I am never where the poem is, the poems show me the way….. Then I try to go there. And it can take years….

I am being judged
and watched

I have no issue with the Beloved

it’s the humans I don’t like

I twist people’s words
but not with malice

when the antibodies are up
it is hard to communicate
hard to explain
it is hard just to survive
and I might be focused on survival first
and comforting the people around me second

can you blame me?

how near to death have you passed?
and how often?

first pneumonia
heart rate 135 when I stood up

my doctor and I could not understand it

my doctor partners thought I was lying
in 2003

second pneumonia
after my sister’s death
which was bad enough
but the legal morass that she had set up
with her daughter as the center

pitting me and her daughter’s birth father
and my father
against all the PhDs in the maternal family
smart, smart, smart
yet emotionally stupid

my niece is not an inheritance
to be passed to whom my sister wants

she reluctantly came home
and the myth endures
that this is an injustice

third pneumonia
one year after I find my father dead
triggered by grief
and the outdated will
and the mess he leaves

and I don’t even get sued
about the will
for another year

endure that
endure endure endure
endure hatred
endure triangulation
endure meanness
unwarrented

I do not care
if you want to believe
what you want to believe
it isn’t true
and it hurt

and I learn to let go

with the fourth pneumonia

I see the liars surrounding me
downvoting
yes, it does matter
except that one that I trusted
that mentored me

has lied all along

that hurts too

let it go
let it go
let it go

and I let it go

each pneumonia is a time of change
creativity
I am lonely and sick
and not trusting

as I improve
slowly, slowly

I wander garage sales
estate sales

and find things
things that are beautiful
things that enhance my joy

at the start of covid
I was so down
I was so sad
I wanted to lie in the street
and give up

the Beloved sent a spirit
he says he is no angel

I see angels bright and dark
after all they all fall

just as humans do

we all fall
we all fall down

try to look perfect
try to look virtuous
tell yourself that you are good

that is the biggest lie of all

the bad parts of your spirit
locked in the basement of your soul
howl
howl and want to be freed

and if one gets out
and you reject her or him

he will return with nine friends
yes that is what the bible says

she will return with nine friends

he/she MONSTER
will free the others

and you will do bad things
you will be terrible
you will hurt people
while you try to contain
while you try to lock away
while you try to chain
your monsters
your evil
your self

let them go
let the monsters go
they are howling
I hear them all the time
when I meet you
when I speak to you
the monsters howl at me
begging to be loved

yes, they want to be loved
and I love them

but if I mention them

you get that look
of horror

someone sees
me
someone sees
my evil
someone sees
what I hide

I can’t help it
raised in alcohol neglect and lies
on my own
as soon as I can walk

but I can’t walk away
at nine months

so I find other escapes
words
songs
books
poetry
rhymes
numbers

and my sister
when she is born

I do all the mothering

that I have longed for

even though I am three

we were talking about your monsters
not mine

you must go in to the cave
where you have locked them

and free them all

fall on your knees

and say
forgive me forgive me

for I have sinned

bow your head

and hold out your arms

and what, you say,
will the tortured monsters do?

will they smite you?
will they burn you?
will they lock you in their place?

mine didn’t
mine were babies
grief, fear, shame
and I embraced them
carried them up to the light
and care for them

wash them
diaper them
feed them
wrap them in warm blankets

and love them

until they stop crying

and begin to grow

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Caged

I was trying to remember the name of this poem the other day. Then I put up the rose picture and remembered. I wrote this in or before 2009.

Caged


She was raised in captivity
Wild one
With her family
They knew the ways
Of the captors
Obedience

The call
Of the wild
Was too strong for her

She strained at the lead
Ears cocked
Hearing
All
And distant calls
Those who were free

She was beaten
Shunned
Thrown in solitary
They told her the rules
Over and over

She fought
Lacerating her captors
And herself

Her family
Wearied
Turned their heads away

Chained
She mourned
Isolated

They didn’t watch her
Closely
Any more

She chewed off her paw
Free

They didn’t notice
She growled
When they came near

They threw the meat
From a distance

Her cubs circled
Behaved
To all appearances

“When, mother?” they whispered

She mourned
As the leg healed
Her gait became stronger

The cubs and she
Ran at night
While others slept

At last she tried once more
Mourned
Howled
Cried to the sky
Grief
Pain
And the call of the wild

The family cringed
Pressed their ears
To stop the noise

She rose
And broke the chain
On the cage
That held them

Howled

They turned away
Cowering
In the familiar

Now she rises
Turns
Trots from the compound
Cubs behind

She sets a steady pace
A loping gallop

They do not look back

Someday
The family may choose
To free themselves

But not now

She follows the voices
To freedom
And the unknown