Category Archives: rural doctor

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Diabetes update

Friday I attended a Zoom diabetes update all day. Sigh. We are really doing diabetes wrong.

Diabetes affected every system in the body and so the guidelines want us to check everything. They made the point that controlled diabetes does NOT lead to blindness, kidney failure, and amputations. Only uncontrolled diabetes. There, do we feel better now?

There are three NEW things to check for. One is CHF, aka Congestive Heart Failure. Heart Failure is pump failure. It makes a lot more sense if you think of the heart as a pump. Diabetes doubles the risk of heart failure in men and increases it by five times in women. We are now to do a yearly BNP (Brain Natriuretic Peptide, got that?) except that it is useless if the person is in renal failure, because that raises it artificially.

The second NEW thing is liver problems. Liver failure is back in the top ten causes of death, having fallen off that list for a while. People drank more alcohol during COVID, there was more drug abuse adding to hepatitis B and C, but the biggest cause is NASH and NAFLD. More acronyms: NASH is Nonalchoholic Steatohepatitis and NAFLD is Nonalcoholic Fatty Liver Disease. This is related to overweight and obesity. Being overweight or obese messes up fat storage and over time this inflames the liver and then cells die, leading to cirrhosis. We are to watch liver tests, think about an ultrasound, and then there are two specific tests for cirrhosis.

Third NEW thing is Diabetes Distress. This is not depression. People score “depressed” on the PHQ-9 test, but don’t respond to anti-depressants. The lecturer said that we have to talk to the patient and find out why they are distressed, or what part of diabetes is getting them down. I thought that we should have been talking to the patient all along. There is a convenient 30 question tool we can use for this, if we have time. Will we?

Now, the old guidelines said that we are to check these things:

HgbA1C every 6 months if not on insulin, every 3 months on insulin and even more in pregnant patients.

Microalbumin/creatinine ratio: a urine test that tells us if the kidneys are starting to leak albumin. They shouldn’t.

Yearly eye test to check for diabetes damage.

Specific blood pressure ranges.

Keep everyone’s LDL cholesterol under 70. So nearly every person with diabetes gets a statin drug.

Do a foot check yearly for neuropathy.

So six things plus the new three. Can’t explain that in one visit and can’t do it in one visit either. I think we should revamp the Diabetes Distress tool and check if physicians and nurses have Guideline Distress. Diabetes is the most complicated set of guidelines other than pregnancy.

Diabetes also takes a lot of time for the person who has it. To check things “correctly”, it takes a minimum of two hours a day for Type II not on insulin and more like three or more for Type I and II on insulin. Think if you have to take two or three or more hours away from your current daily activities and devote it to diabetes. No wonder people are distressed.

The medicines are also confusing. Wegovy is in the same class as Ozempic, but is FDA approved only for weight loss in people who are overweight and have a complication, or people who are obese. Ozempic is for diabetes but people often lose weight so think about it if the person is overweight. Some of the medicines in that class also are approved to reduce the risk of heart disease, which goes up with diabetes. Another class has medicines some of which have approval for diabetes and others for diabetes and renal problems, BUT don’t use it if the eGFR is under 20, got that? The lecturer on medicines said that we’ll see less in each of those classes after they fight it out for dominance of the market. He’s been an endocrinologist for 30 years and remembers when the very first non-insulin medicine was approved. Cool! He is not discouraged, but another lecturer said that we have one endocrinologist for 5000 people with diabetes, which is not enough. We were encouraged to do more continuing medical education.

There is one guideline that I disagree with and would like to see changed. I will write about that next. After I memorize all of the different things the new medicines do, which is changing every month as new research comes out! Stay tuned!

I think I will put the clutch in and coast a bit. Or perhaps clutch handfuls of hair and pull at them, I don’t know.

For the Ragtag Daily Prompt: clutch.

I hiked again yesterday and had a very cooperative bunny stop for a snack in camera range.

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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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Gauging fossils

I like to think about various men
My mind wanders engaging in theory
I have no urge to date again
Getting to know you makes me weary
My husbands welcome seemed less than more
Coming home I felt alone
Now I’m welcomed at the door
I am happy: my cat is home
I like men best now in the abstract
My imagination is a happy place
Real life ones really don’t attract
I am au courant with “leave no trace”
My daughter dismisses the men near my age
Misogynist fossils is how they are gauged

_____________________

For the Ragtag Daily Prompt: trophy.

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Unclean

Housework is a slightly sensitive word for me today.

Sol Duc and I moved two days ago, from the Hilton Home2 Go (NOT recommended if you are long term and want to cook) to a furnished house.

Wonderful, right? Except the stove was all splattered with grease inside, the microwave grease and a dirty paper towel and the refrigerator was all fingerprints. Ick.

I called the rental person and he showed up with cleaning gear and did a cursory clean. I did the fridge. Then I started thinking. The only cleaning equipment I brought was new sponges, so I started washing out drawers and they are ALL dusty. This place was NOT cleaned. And the photograph is the grill in back: filthy AND there is no cleaning equipment. The two tables are built for someone taller than me, so I looked at a plastic table in the garage to use for a desk. There is a card table of cork in the garage. And behind the card table is mouse poop and a dead mouse. I return the card table and get out of there.

Now I am grossed out and annoyed. I contact my temp company and the rental person. “Has poison been used in the garage?” I ask, for Sol Duc’s sake. “And what about the yard?”

“No, no, no spraying. There has never been any evidence of pests there.”

“Well, there is evidence now.”

Right after our conversation, the Round Up truck arrives to spray weeds. Um, no. So I contact my temp company. The rental guy sets up a service to come clean. “Garage too, and I want everything pulled out from the walls.” Ok, there are cardboard boxes and stuff that belongs to the owners in the garage. Mouse heaven, honestly. And my impression is that this rental person is NOT going to tell the owners about the mice. I don’t trust him a bit now, so I only want them to clean when I am present, which means Wednesday at 6 pm. And there is no way they’ll finish the garage that night unless they are cursory. I want the floors and bathrooms cleaned. I have already done shelves and drawers. The stove racks aren’t clean.

I am NOT cleaning that grill. I am also NOT buying grill cleaning equipment. It is hella annoying.

I’ve always left places AT LEAST as clean as I found them. I think this rental person is not truthful. He said it’s the owner who has the weed spraying service, but then he should have said, “I don’t think so.” So there could well be rodent poison in the garage, he has no idea and won’t check.

Ick. Some people are really icky.

For the Ragtag Daily Prompt: housework.

Yeah, I am thinking of the scene in the second half of the song. Yep.

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Soldier on

Older
bolder
golder
told yer
moulder
soldier on

What is older? Anything and anyone older than me? At one point I have 5 women who are over 100 years old as patients. Two are 104. One is local indigenous tribe and tells me about white women moving to another pew if she sat down near them in church, back when she is in her twenties. I am apologetic at that visit because it is hospital week. Our pacific northwest hospital has chosen cowboys as the theme so being a bit oppositional defiant, I have braids with one feather hanging down. I swear that EVERY ONE of my indigenous patients comes in, including the 104 year old. I apologize, but they mostly seem amused by my rebellion.

They also influence me. Now when a 72 year old complains about being OLD, I say, “You are not old in my practice.” They look confused. I say, “I’ve had five people over 100 all at once, so you don’t get to complain about being old until you are 90.” People laugh, but they also usually look pleased. Over 100 is a LOT older than 72. When someone is over 100, I don’t really doctor them much. I might say, “This is what the book says we should do.” “I’m not doing that,” says my 101 year old. “Ok, cool.” I say. It’s hard to argue with.

And the joke about the centurian? What do you like best about turning 100? “No peer pressure.” Um, yes. I want them to tell ME what they’ve done to reach 100. The one thing that they all have in common is that they are all stubborn. I don’t know if stubbornness is what gets them there or if we just get more stubborn as we get older. Both, perhaps.

By stubborn, I don’t mean that they don’t learn and do new things. I had a woman in her upper 70s who I diagnosed with diabetes. At the next visit she said cheerfully, “I found these five apps for my phone. This one tells me the carbohydrates, this keeps track of the distance I walk, this one tracks my blood sugar.” I don’t remember what the other two did. This was a decade ago. She was retired from Microsoft. I wanted her to teach a class for me and all of my other diabetic patients.

My grandmother took classes in her 80s in lip-reading. She was going quite deaf and her hearing aides were not terribly helpful. She had videotapes and a rather shy teacher who would come to the house. She would glare at him and the videotapes. She attacked learning it like a piranha and was furious that she couldn’t learn it faster. I am like that too and my son learned some patience from the violin. He couldn’t play well immediately and found that practice works.

At what age is someone old? I think that’s moving target and the older we get, the older we think it is. I do think 104 is a lot older than 72. When does your culture think that people are old? My fierce grandmother said that she would look out her window. “I see little old ladies across the street and think, oh, poor things, they are so old. But then I think, OH, I am older then they are!” She died at age 93, fierce until the end and curious about death too. Her last words to my father were, “Look, Mac, I’m dying.” He said, “I’m looking,” and she stopped breathing. She was always curious and funny and could tease quite terribly and she and my mother butted heads and loved each other. She loved my father too, and me.

The photograph is my maternal grandmother, Katherine White Burling and it’s one I took.

For the Ragtag Daily Prompt: older.

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Moving

Sol Duc and I moved yesterday. The place we were in was billed as having a kitchen. It has a refrigerator, dishwasher, sink and microwave. NO STOVE! AUGH! I could check out a hot plate with one frying pan. I would describe this as a fast food kitchen. Ugh. I like to COOK. I also found a nice farm stand and bought a bunch of vegetables. The farmer said, “Thank your parents for raising you right with vegetables.” Heh. I will go back.

We are now in a small house, at the western edge of Grand Junction, with two bedrooms! Now my daughter can visit again. Sol Duc worried about the ceiling fans and hid under the bed for most of the day. This morning the fans are off and she is exploring. We have a fenced yard, though she won’t go out without harness, leash and me. We are in the southwestern corner of the development and there is another development across the street. It only has three houses, so we have lots of area to wander around. This am we are out at 5 am and can hear roosters from the farm kitty corner to us. And cows. We have a fabulous view of the mesas to the south and west and we are no longer surrounded by parking lot and highways. The local Coloradans seem to really love their pickups and especially loud ones. The valley acts like a bowl and highway sound travels a long way.

We both miss Elwha. Sol Duc was fairly panicked when I loaded the car and put her in the crate. I think she was afraid we were going to drive for three days again. She likes the house though and came out to purr last night. This morning she is exploring. I am keeping the second bedroom closed since my daughter doesn’t do very well with fur.

We still hope that Elwha turns up. Come back, Elwha!

I will go finish checking out today. I had to have Sol Duc out of the room we were in twice a week for an hour, so that they could come in to clean. That was fairly stressful for both of us. The instructions they gave us were confusing and it was eight days before they explained the rules. Which did not match the written rules. Anyhow, I am OUT OF THERE. Some of the staff were really nice. Others, well.

I had more stuff to move than when I arrived, all food. The new place is great though built for tall people. I am not tall. I am now on the lookout for a desk, because all the chair/table heights are wrong for me. I will ask the rental folks first.

My Ex and I used to dance to Saffire, way back in Richmond when I was in medical school. Fabulous and here is a song about rising.

For the Ragtag Daily Prompt: rise.

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Cool

I am still wearing sweaters to work.

It is high desert here. One morning it was really pretty cold when I walked Sol Duc in her harness. Really she walks me. Cats are like that. But I wished for mittens. The temperature was 38. The last few days the low is in the high 40s or low 50s. Two days ago it was 90 driving home from work.

The consequence is air conditioning. I do not have air conditioning on the Olympic Peninsula. My house is from 1930 and well designed to stay cool in the summer and we rarely hit 90 anyhow. Two summers ago my heat pump switched to cooling when we had one hot week, startling me. We did hit 100 one day in Port Townsend, but it still dropped thirty degrees at night because of the cool Salish Sea surrounding us. My patients would complain of the awful heat when we got to 80 degrees. It’s all relative, right?

Here in Grand Junction, we are just starting to heat up. The hottest time appears to be around 4 or 5 pm.

I was cold at work all day two days ago. I wore a linen shirt over another shirt and it was not enough. I went outside at lunch and heated up nicely in the sun. Yesterday I took a wool jacket with me. Air conditioning is very strange.

This morning it is 51 now and projected to reach 85. The high desert temperature change of 30 to 40 degrees is not that different from home, but the air conditioning is different.

For the Ragtag Daily Prompt: ambivalent.

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Sweet hike

I had a sweet hike on Sunday and met some of the locals.

I met bun and another small mammal who moved too fast for a photograph.

I haven’t quite sorted out my local lizards.

My! Some of the locals are SO colorful! I like the yellow feet!

And here is part of the trail that gets it the name Corkscrew.

For the Ragtag Daily Prompt: syrup.

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Travel light

Pormanteau
Passepartout
What do you know?
Where will you go?

Around the world in eighty days
1873 writer braves
a story to stun and amaze
journeying difficult yet craved

And do we now want it all?
Explore and travel still don’t pall
Yet changing weather makes cities fall
What change will make us heed earth’s call?

No Passepartout to pack my bags
Ethics queries about plane rides
A portmanteau inside my mind
Books are trips, to earth be kind

For the Ragtag Daily Prompt: portmanteau.

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Peak

The pendulum swings far and back
Too many babies, what will we all eat?
Suddenly the switch, another panic attack
Now too few to support Wall Street
We wait in running cars in the drive-thru line
Wanting our turn to order fast food
It’s sunny through the smog and we feel just fine
The weather’s getting stranger, the world in a mood
Maybe we’ve peaked while driving around
Who will take care of us when we are old?
Peaked at the drive-thru, going down without a sound
An AI wonders at the price of gold
This might be as good as it gets
Maybe an AI will keep a few of us as pets

For the Ragtag Daily Prompt: drive-thru.