Category Archives: rural doctor

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Doing the best with what you have

Medicare doesn’t cover everything.

It can’t. There are new things being thought up all the time. Some are legitimate and some are scams. There are tons of quack medicine videos and supplements and stuff on line.

But there is also a matter of personnel and resources. Sometimes we do not have enough. Then we have to do the best we can with what we have.

There is a particularly difficult case from my second year of rural Family Medicine with Obstetrics. Things went right but just barely. This is from memory and over 25 years ago, in the 1990s, so I can’t violate hipaa because I can’t remember names from then. Mostly.

I had a pregnant woman whose pregnancy had gotten complicated. Her ultrasound showed an abnormal placenta. Very rarely, the placenta can grow into the uterus too far, and form a placenta increta. Even more rarely it can grow THROUGH the wall of the uterus and into another body part. That is called a placenta percreta.

In this case we thought that the placenta had grown into the bladder. We were not certain. The obstetricians were aware. Our patient was aware. A cesarean section was planned for when the fetus was mature.

Then she developed a second pregnancy complication. Preeclampsia. This is a complication where blood pressure rises, there is protein in the urine and many things can go wrong. It can progress to eclampsia, which means seizures. This is Very Bad, which means the mother and fetus can die.

She developed HELLP syndrome. This is an acronym. The P is what I worried about, platelets. Platelets help your blood clot. Her platelet count was dropping out of sight. We were rural, 180 miles from the nearest high risk obstetrician. We did have blood for transfusion but NO PLATELETS.

The treatment for preeclampsia with HELLP syndrome is to deliver the baby. I called our obstetrician the minute I got the lab result. “No platelets — can I fly her out?”

“YES! FLY HER OUT!”

Transfer to a bigger hospital with facilities for a premature infant and with platelets, because she needs a cesearean section and she could need a hysterectomy if that darn placenta has grown through. Messy.

Problem number three: weather. We are in Alamosa, Colorado, at 7500 feet, which is the valley floor. We are surrounded by 14,000 foot peaks with passes in four directions. That nearest hospital with platelets is 180 miles and over a 10,000 foot pass and it is snowing.

I call Denver first. 250 miles. Fixed wing life flight. Nope, the weather is too bad to the east and north.

I call Albuquerque. 250 miles. Nope, the pass is socked in, the plane can’t get through.

I call Grand Junction. About the same distance. They say “WHERE are you?” I’ve never tried to send anyone there before. They demur and I cajole and beg. “Okay, okay!” The high risk obstetrics doctor can’t be looking forward to meeting this patient, but they accept.

From the start of calling to the arrival of a plane and crew usually takes about four hours. I want to chew my nails.At last I hug my patient goodbye and they go.

I get the call about 6 hours later. Delivered and they did have to do a hysterectomy, but mother and baby are fine. Her bladder was untouched. They had platelets.

Whew! I was so happy, and mom and baby too. Let’s give credit to my patient too: she got prenatal care. She paid attention. She knew she was high risk. I had told her to come in if anything changed and she did, so we caught the preeclampsia on time.

But it could have gone wrong in all sorts of ways. We were both careful and we were lucky. If the storm had been over Alamosa we would have done the best we could then, too, but it could have turned out quite differently. And thanks to the high risk obstetrics doctors who accept complex patients that they have never seen from rural doctors like me!

Blessings. Blessings on all the nurses and doctors and midlevels and hospital housecleaners and security and lab workers and the Life Flight personnel and First Responders and everyone who has worked and worked and worked through the pandemic.

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I took the photograph in Maryland in December: abstract and complicated water, ice and reflections.

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Medicare Disadvantage

Medicare Advantage plans, from for profit insurance companies, are being rebranded Medicare Reach.

They seem like a good deal. They are if you are healthy forever! So what is the catch?

In Michigan I go to look at a nursing home with a friend. The administrator shows us around. Small rooms with two beds. We also look at an assisted living. Much larger rooms, the friend can stay overnight in the private room with the parent, at a cost of $4000.00 per month. Her insurance will not cover it.

But back to the nursing home. The administrator tells us that it’s good that her parent does NOT have a medicare advantage or medicare reach plan. “It is nearly impossible to get the insurance companies to approve a rehabilitation stay at a nursing home.”

“Really?” I say.

“Oh, really.” She says. “The insurance companies certainly don’t want you to know that when you buy their “deal”.”

So, the for profit insurance companies want you if you are of medicare age and are well. BUT the catch is that they really don’t want to cover if you are sick. Think carefully before you buy a pig in a poke!

Physicians for a National Healthcare Program is working to stop the insurance companies from skimming profit off the healthier elders and then abandoning them when they are not healthy. I wish that the United States citizens would clue in, get mad, and vote for single payer! Write your congresspeople and put pressure on them! They listen to money but in the end, they live by votes. Make sure you look at the fine print, because the insurance company is there to make a profit off you, not preserve your health.

The picture is Mordechai, our plastic clinic skeleton, distrusting Profit-Over-Health Insurance Companies.

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Long Covid fatigue and overdoing

I’ve been reading journal articles about Long Covid. The three primary symptoms are fatigue, shortness of breath and brain symptoms. Mostly brain fog. Then there is a long long list of other symptoms.

For the fatigue, the journals are recommended graded increase in activity “without triggering a fatigue crash”.

Now, that is all well and good, except it’s a moving target. The amount of activity one can do is NOT static.

I have something that caused CFS-ME. My fast twitch muscles came back on line sometime between Christmas and New Years. GREAT! Then I was helping a sick friend until January ninth. I flew home and then there is all the unpacking and bills and catching up and sweeping up catfur dust elephants. Finally I got to exercise. I walked a couple miles on the beach one day and then around town with a friend the next.

Which crashed me. The third day I spent lying on the couch. My muscles basically were ALL hurting and saying, “We hate you.”

The fast twitch are back on line but they are weak as newborn kittens. For the first two days I felt strong and normal. The third day I felt like a steamroller had gone over me.

So did I do the wrong thing? Well, no. I won’t know what I can and can’t do it unless I do it, right? After four rounds (or more) of pneumonia with muscle weirdness, I can tell when it’s improving. Then I have to rebuild the working muscles. Also my slow twitch posture muscles are frankly pissed off and have been doing all the work and are not very interested in working with the fast twitch when they first come on line. “Where have YOU been? We’ve been doing YOUR work AND OURS.” I have to learn to walk again.

I was doing well with pulmonary rehab in the fall, building up on the treadmill twice a week, until I got my flu shot and then my Covid booster. Well, they are supposed to raise antibodies. Unfortunately they raised the ones that make my fast twitch muscles not work. Muscle blocker antibodies. I am just glad that my slow twitch work, because I sympathize hugely with the people who end up lying in bed. It’s still inconvenient, difficult to explain and annoying.

At any rate, gentle graded increase in activity is all very well as advice. But do you control everything that happens in your life? I don’t. Someone gets sick, the mail goes awry, a billing company changed their address and I didn’t get the memo. It all takes energy. Some days I am going to overdo, especially when I feel better. And it rather sucks to lie around the next day, but it is ok.

Over the last week I had a friend up from Portland. We walked three days running. On the third day we walked paths from my house to the lighthouse and back. About 5-6 miles. I was not quite limping when I got home, but I knew I could rest the next day. My muscles got HUNGRY and are continuing to improve.

So when your doctor tells you “graded activity to avoid fatigue crashes”, remember that it is not wholly controllable because life is not wholly controllable. Some days you will do great and others, well, hmmm. That was too much.

Blessings.

https://www.aafp.org/pubs/afp/issues/2022/1100/long-covid.html

https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html

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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

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For the Ragtag Daily Prompt: chuckle.

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Petty lie

What old deep wound causes you
to hurt me and other friends you’ve had
in past. What terrors hidden in that brew
make you glory in making others sad?
You boast to me of throwing people out
of your life forever, never friend
again. You don’t explain what crimes reroute
your heart to where you never speak again
to him or me. How many people discarded
from your heart and at what interval?
How many “friendships” have you departed?
And yet you boast that others call you spiritual.
“Friends forever,” you said. I wonder why
you tell yourself and me that petty lie.

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Sonnet 8

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Small hopes

Alone today and quiet, happy with it
“I think you write more than I do, even though
I write for a living.” “I love it,” I say.
It is my daily quiet writing time: four am.
No one is here but me and the cats
and they just ate and are grooming each other.
Just me and paper and pens and computer
still dark out and cold. I check to see if it is clear.
No, not today. I hope to see the green comet.
Little hopes, small ones, quiet ones, that do not
bother anyone. No one is jealous or wants to take them
away. I hold them warm in my heart, Beloved,
and do not think of love.

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For the Ragtag Daily Prompt: temptation.