Category Archives: rural doctor

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Long Covid imaging

In the last Long Covid talk that I attended and wrote about (here: Pulmonary Manifestations of Long Covid), the pulmonologist and intensivist says that one problem with Long Covid is that we do not have imaging that can “see” it.

That is, the chest x-ray looks normal, the echocardiogram may look normal (heart ultrasound), the chest CT scan may look normal, a brain CT or MRI may look normal, but the patient may still be tachycardic, feel exhausted, feel brain fog and have multiple other symptoms.

That pulmonologist listed five of the top mechanisms that are prolonged in the immune system. Most of the scientists and physicians are framing this as “immune system dysfunction”. I am not. I am framing it as “you were really really sick and your immune system is still on high alert and trying to protect you so you can recover”. Now wait, you say, how could chronic fatigue like symptoms protect me? Well, if you are exhausted, you can’t go to work and you’ll stay quiet at home most of the time and less exposure chance. But what about brain fog? Again, this will slow your interaction with other people and force you to rest and heal. But, you say, I don’t like it. Well, yeah. Patience. We call grumpy patients that are recovering “convalescents”. It is a good sign when they are grumpy and over it and just want to be better. That doesn’t mean I can make myself or anyone else heal faster.

The pulmonologist says that the best test is the six minute walk test. This is usually done by a respiratory therapist. The person walks in a circle for six minutes wearing a pulse ox, with the respiratory therapist doing regular checks. This distinguishes between the people who have primarily a lung issue from all the other issues. If the person is tachycardic (fast heart rate) but not hypoxic (oxygen level dropping), then it’s not primarily lungs though blood clots to the lungs sometimes have to be ruled out. One of the mechanisms in the immune system is microclots and an increased risk of blood clots. That can mean heart attack, stroke, or pulmonary embolus, a clot in the lungs. The microclots are suspected of causing some of the muscle fatigue and exercise intolerance, by clogging capillaries and reducing oxygen flow to muscle cells. Muscle cells do not like this at all.

I have done my own quick walk test with patients since 2003, when I had terrible influenza. About a week after my influenza started, with the temperature of 104 and heart rate at 100 at rest and 135 walking, my temperature came down. However, the fast heart rate continued. Normal heart rate is 70-100 and 135 walking will make you feel exhausted. I lay on the couch and could barely make my kids dinner for two months. It resolved then. I read a book about influenza and thought that I had “influenza viral pneumonia” where there is lung tissue swelling, reducing the air spaces, after influenza.

My quick walk test in clinic is to check a sitting oxygen level and heart rate and then have the person walk. I would have them walk up and down a short hall three times then sit down. When they sat, I watched the pulse oximeter recovery. Some people would jump from a resting heart rate of 62 to a walking heart rate of over 100, say 120. Their oxygen level could stay normal or it could drop. If they dropped below 88, I would get home oxygen and forbid them to return to work. If their oxygen level held, then they needed to rest until their walking heart rate stayed under 100 and they were no longer exhausted by gentle or normal activity. If they return to work with a walking heart rate of 120, they will be exhausted and are more likely to get a secondary pneumonia or have other problems. The heart does not like to run at 120 all the time. You can see why a person who already has some coronary artery blockage would be more likely to have a heart attack if they get pneumonia from influenza or Covid-19.

The conferences I am attending are talking about “targets” in the immune system. That is, new drugs. I think the science is wonderful and amazing, but I also think we need to step back and say, this is a really really bad infection and some people need a lot of support and reassurance and time to heal. Reassure them that even though they have not yet returned to normal, the immune system is working hard to protect them from other infections and it is saying very very loudly that they need to rest. Rest, recuperate and trust the immune system. Some things need immediate treatment, especially blood clots, heart attacks and strokes, but once those are ruled out, we need to support people through their convalescence and healing.

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The photograph is from April 2021, a few days after I was put on oxygen. A selfie.

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Boat for sale

Sun Tui is a 23 foot sloop, built in Hong Kong by American Marine in 1960. She is plywood sided and has a nearly full keel. The crane operators yesterday say that she weighs 5000 pounds: that keel makes her very very stable to sail. The tiller is a carved dragon with the world in its’ mouth and there is a carving of Kwan Yin inside.

My daughter and I used a 40lb trolling motor to drive her through the boatyard yesterday. That is equivalent to 1/2 horsepower, but the little motor could still move the boat. There was very little wind or waves. We got to the smaller of the two cranes. The crane operators measured Sun Tui and then looked at the trailer. Huge thanks to my friend R! He and I replaced the tail lights on the trailer two days ago and he brought it to the boatyard. I don’t have a truck.

Here my daughter and I are waiting until the crane is in place and the slings are lowered.

We motored slowly into the sling. The crane operators caught the boat and held it with boathooks while the operator slowly started lifting the slings. We rode up to the street level, they moved the boat towards the street, and we stepped off. The boat is raised until it can be carried through the boatyard.

Here she is pressure washed, to help prevent species from moving from one place to another.

Rolling. We have one huge crane and three smaller. This is one of the smaller ones.

They were very careful and thorough putting Sun Tui on the trailer.

On the trailer, but not home yet! The mast is too tall to go through town without hitting wires that cross streets! Next we go to Haven Boatworks, where a second crane removes the mast and the shipwright helps secure everything.

All packaged for transport!

Now Sun Tui is at my house, ready for further cleaning and work. I hope that we find her a new home and much love!

I sent my son the final photograph and he sent back “Congratulations!” Hooray!

For the Ragtag Daily Prompt: congratulations.

For further information about owning this boat, email me.

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Humanlike? uh-oh.

Martha Kennedy’s post “Humanlike? Naturally…” almost makes me want to play with ChatGPT.

But. I worry about AI.

Why why why?

It is written by humans. Humans are trying to make it respond like a human. I don’t trust humans. Ok, I trust a very few.

My career as a physician started as a way to do science without a PhD and also to try to understand people. Understand them for writing.

I’ve been a physician for over 30 years and I still do not understand people. People do horrible things to one another. Just watch a divorce or a family lawsuit after a death or a war. People can be and often are horrible. They can be noble and loving too. Sometimes.

But, you say, ChatGPT eschews emotion.

Yes, well, I don’t believe it. It is being taught to respond as if it has emotions. Where is the line between responding as if it has emotions and actually having emotions? Oh, those are just ones and zeros, it’s a machine. Our emotions are chemical and electrical, hormones and neurotransmitters released into a complex neuron network, often to respond faster than we can think. We pull the finger out of the flame almost before we feel the pain. The response to the braking car in front of us, the deer running out, a ball followed by a child: the electrical and hormonal response is faster than conscious thought. So if ChatGPT is taught to respond to human emotions, isn’t that like our own evolution? Emotions and thought are both important to our survival with other humans. Emotions get the short end of the stick right now and the culture pretends that we can all be positive all the time. I think that is silly and insane. We should not be positive about war or child abuse or injustice or discrimination. Keep working for change, though it’s important to take time off too, because it can be exhausting.

Humans have a slow trek to emotional maturity through their lives. I wonder if ChatGPT will have a similar trek. Imagine tantrums in an AI or separation anxiety or the AI falling in love and being rejected. If humans program AI to be human, it will not be logical. It will be logical and emotional and may feel hurt when it makes mistakes. Imagine an AI sulking.

I took the cats and deer photograph yesterday.

For the Ragtag Daily Prompt: starch. They are talking about AI writing patient notes. What could go wrong? Makes my neck feel stiffer than a starched shirt!

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A-typical

My daughter and I went to Rialto Beach two days ago. We hiked the beach, returned and found our campsite. I bought my lifetime National Park Pass, but the park sites were full. We found a nearby private campsite that was just fine. My daughter gave it an A- for restrooms, a B for the sinks with hoses bringing cold water and a D for the regular not-bear-proof garbage cans.

After setting up the tent and dinner, we returned to Rialto for the sunset. Quite gorgeous, with the sun sinking in to the Pacific.

Earlier a ranger checked in when we were past Hole in the Wall. My daughter said, “Low tide at 3:45 and we will head back soon after that.” He grinned. Hole in the Wall is full of water when the tide is in. We could cross via a path over and behind the rock.

We wanted to see a whale, but mostly we saw rocks that were not whales. The tidepools are gorgeous.

There also were lots of brown pelicans. Wow, can they fly beautifully. My daughter points out that they look way more like airplanes than either eagles or great blue herons. It’s the wide body and the landing gear retracted and the really long glides.

They can stall and then dive.

We had a lovely trip. Meanwhile, I did not take my laptop. TYPING WITHDRAWAL! I had my journal, of course.

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For the Ragtag Daily Prompt: type.

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Rescue

A friend stops speaking to me. Nearly a year ago. I particularly mind because this person said, “We will always be friends, no matter what.” I am skeptical of always/never statements, but I want it to be true.

I run across him and he is in trouble. He has boxes, cases, six by four by six feet. Stuff he finds valuable, though it’s not anything I value. He is outside with the cases and is being threatened, told to hand them over.

It’s not a dramatic rescue. I just walk up and say “Hi,” to him. I am there, I am a witness, I look over my shoulder. There isn’t anyone else with me, but the implication is there. The threatening person leaves.

The former friend looks at me. “We’d better get the boxes inside,” I say, “Until you can move them.” We are by my house. “You can have upstairs and I’ll take the basement.” He looks uncomfortable, but he can’t leave his valuables on the street. “Or I will take upstairs and you the basement.” He still looks awkward. “Ok, or we can both be on the same floor, I don’t care.” He looks away. He says, “If we are on the same floor, I will want to kiss you.”

“Oh,” I say, and wake up. It’s a dream. It’s not him. It’s what my brain thinks he could/should be? Good luck with that.

Still, I decide that we should be on different floors. He has not spoken to me for a year and I don’t trust the friendship and certainly no kissing. I want him out of my house as soon as he can arrange transport for the four boxes. If he wants to renew the friendship then, he can contact me.

However, there is a shift in me. How odd that a dream can do that. I feel less upset about the whole thing. I like the version of him that my dream brought me, even though it isn’t real. It’s real in my dreams. Maybe that is enough. I feel more comfortable and happy.

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I took the photograph two days ago at Rialto Beach. The Hole in the Wall rock looks like a giant elephant. My daughter and I hiked the beach and camped for a night near by.

For the Ragtag Daily Prompt: karma.

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Cord stories

I would tell my pregnant patients not to let anyone tell them a really difficult delivery story until after their own delivery. “Blame me,” I would say. “Tell them your doctor says you can’t listen right now.” So if you are pregnant, read this after the baby arrives.

Umbilical cords can be scary.

I delivered babies as part of Family Practice for 19 years. I was good or lucky or both. I still saw scary umbilical cords. Cords with a true knot, where the baby has managed to tie a knot moving around. More than one of those, not tightened down. Cords with two blood vessels instead of three, which can be associated with birth defects or genetic abnormalities, but not always. Cords with an abnormal insertion. I was waiting for the placenta once, with the baby in mom’s happy arms. One puts “gentle traction” on the cord to tell when the placenta is ready. I felt like the cord tore a little. I promptly call the ob-gyn. He arrives and tears the cord off. He then gives mom some “forget this” medicine and very gently gets the placenta with a ring forceps. The cord had a velamentous insertion on the placenta. This means that instead of going all the way to the placenta and diving in and spreading, the three vessels separated a few inches from the placenta. Not very well attached and I had torn one of the three vessels. Mom and baby did fine and I was glad I had called the ob-gyn. One of the scariest umbilical cords was normal but wrapped four times around that baby’s neck. Luckily I had called the ob-gyn, she agreed something was off and mom agreed to a casaerean section. Whew.

Most umbilical cords are not scary and most deliveries are wonderful. I loved holding new babies and saying hello and welcome.

The photograph is my son, about four hours old.

For the Ragtag Daily Prompt: umbilical.