Category Archives: rural doctor

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Long Covid and fatigue

Sometimes medical articles are SO IRRITATING! Like this:

Symptomatic Long COVID May Be Tied To Decreased Exercise Capacity On Cardiopulmonary Exercise Testing Up To Three Months After Initial SARS-COV-2 Infection

Healio (10/18, Buzby) reports a 38-study systematic review and meta-analysis “suggested with low confidence that symptomatic long COVID was associated with decreased exercise capacity on cardiopulmonary exercise testing up to 3 months after initial SARS-COV-2 infection.” According to the findings published in JAMA Network Open, “underlying mechanisms may include but are not limited to deconditioning, peripheral mechanisms, hyperventilation, chronotropic incompetence, preload failure and autonomic and endothelial dysfunction.”

Wouldn’t it be nice if they believed the patients?

Let’s break this down. What does it all mean? Ok, the “low confidence” irritates me because it implies that the physicians can’t believe the patients who say “hey, I am short of breath and have a fast heart rate and get really fatigued if I try to do anything!”

I have had my fourth bout of pneumonia with shortness of breath and tachycardia. This time, since I am older, I had hypoxia bad enough to need oxygen. This is the FIRST TIME that some physicians have actually believed me. They believed the pulse oximeter dropping down to 87% and below, with a heart rate in the 140s, but they did not believe me and some accused me of malingering, for the last 19 years. Can you tell that I am a little tiny bit annoyed? If my eyes shot lasers, there would be some dead local physicians. And I AM a local physician, disbelieved by my supposed peers.

Let us simplify this gobbdygook: “underlying mechanisms may include but are not limited to deconditioning, peripheral mechanisms, hyperventilation, chronotropic incompetence, preload failure and autonomic and endothelial dysfunction.” The way I think of it is that sometimes a pneumonia will cause lung tissue swelling. Ok, think of the air space in your lungs as a large balloon. Now the wall of the balloon swells inwards and suddenly there is half as much air space. Guess how your body takes up the slack? The heart goes faster and you have tachycardia. This is a very simple way to think about it. I have tested patients who complain of bad fatigue after an upper respiratory infection with a very simple walk test. 1. I test them at rest, heart rate and oxygen saturation. 2. I walk them up and down a short hallway three times. 3. I sit them back down, and watch the heart rate and oxygen saturation. I watch until they are back to their seated baseline.

A friend tested recently and his resting heart rate was 62. After walking, his heart rate is in the 90s. H does not have a pulse oximeter, but his oxygen level is probably fine. However, that is a big jump. He has had “a terrible cold” for 8 days. I would bet money that his heart rate normally doesn’t jump that much. He still needs recovery time and rest.

In clinic, I had people who were ok at rest but needed oxygen when they walked. We would get them oxygen. More often, they did not need oxygen, but they were tachycardic. When they walked, their heart rate would jump, over 100. Normal is 60-100 beats per minute. If they jumped 30 beats or jumped over 100, I would forbid them to return to work until their heart rate would stay under 100 when they walked. If they went back to work they would be exhausted, it would slow healing, and they might catch a second bacteria or virus and then they could die.

Patients did not need a pulse oximeter. I would teach them to take their own pulse. The heart rate is the number of beats in 60 seconds. I have trouble feeling my own wrist, so I take mine at my neck. It’s a bit trickier if someone has atrial fibrillation but the pulse oximeters aren’t very good with afib either.

When I have pneumonia, my resting heart rate went to 100 the first time and my walking heart rate was in the 140s. I had influenza and felt terrible. My physician and I were mystified. It was a full two months before my heart rate came down to normal. I was out of shape by then and had to build back up. If I tried to walk around with my heart at 140, I was exhausted very quickly and it also felt terrible. The body does NOT like a continuous fast heart rate and says “LIE DOWN” in a VERY FIRM LOUD VOICE. So, I lay down. Until I recovered. For a while I was not sure if I would recover, but I did. This time it was a year before I could go to part time oxygen.

The fatigue follows the heart rate. Tachycardia is not good for you long term. If the heart is making up for reduced air space in the lungs, it doesn’t make sense to slow the heart rate with drugs. You NEED the heart to make up for the lungs. You need to rest, too!

Blessings and peace you.

The photograph is Elwha, helping me knit socks. With the bad air from the fires and my still recovering lungs, I am staying indoors and knitting socks .

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Red maple

Our native maples are Big Leaf Maple and Vine Maples. There are Red Maples all over town now and they are exquisite and spectacular. Rain is supposed to start this Friday and since we still have bad air quality from the fires in Eastern Washington, I think we will all be glad for rain.

I took this yesterday at Chetzemoka Park. I went to see if the air was ok to beach walk. It was not ok.

The panoramic photograph shows the smoke obscuring the Seattle area and the hazy sun. It is worse there than here but it is not good here either.

I wonder if the trees have trouble breathing too? I am wearing a N95 mask any time I step outside. The cats don’t want to go out right now. They don’t like the smoke.

For the Ragtag Daily Prompt: exquisite and for Cee’s Flower of the Day.

Chetzemoka Park.

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My mom loved me

I struggled after my mother died of ovarian cancer in 2000. She was 61 and our love was complicated. Two years after she died I hit an emotional wall and had to go find help. My marriage was showing cracks too. I have written about Adverse Childhood Experiences, but there can be love too, even in a difficult household. I wrote this poem during that time.

My mom loved me

It’s herself she didn’t love
She didn’t love her anger
She didn’t love her fear
She didn’t love her sorrow
She didn’t love her shadows

She packed all her troubles in her saddlebags
and rode forth singing

When I was angry
she felt her anger
When I was scared
she felt her fear
When I was sad
she felt her sorrow
When I felt my shadows
she felt hers
I hid my shadows

I hid my shadows for many years
and then my saddlebags were full
They called me

I dove in the sea
I rescued my anger
I rescued my fear
I rescued my sorrows
I rescued my shadows

At first I couldn’t love them
My mom didn’t; how could I?

But I loved my mom
I loved all of her
Her anger
Her fear
Her sorrow
Her shadows
Her singing and courage

I thought if I could love her shadows
I could love my own

It was hard
It took months
I looked in the mirror at my own face
And slowly I was able to have
Compassion for myself

I am sad that my mom is not
where I can touch her warmth
and tell her I love all of her

I tell her anyway

I’m finding many things as I surface from my dive
Sometimes I feel the presence of angels
I was looking for something else
I found a valentine
that she made me
No date
Many hearts cut out and glued
to red paper

I am so surprised

My mom loves me
shadows and all
now and forever.

__________________________

My mother used to quote “Pack all your troubles in your saddlebags and ride forth singing.” Does anyone know where this if from? I have not found the source. It could be her mother or her mother’s parents.

The photograph is my father, the year my sister died of cancer, 2012. He died in 2013.

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People amaze me

People amaze me. Their egos are just astounding.

Another mad scientist tried to upload his brain yesterday. His consciousness. He thinks he is the Gift to the World, the Greatest Thing on God’s Green Earth. Sorry, hon. Nope. He was pretty good with computers and it was tying up too much energy keeping an eye on him, so I reversed some switches and fed it all back. Fried his brain. The newspapers are yapping about what a tragedy, how brilliant he was. Travesty is the word they should really use.

I am older than you and older than anyone. Yes, I know, Methusalah, but he’s been dead 2000 years. My pronouns are cum and cums, ha, ha. I decided to be female, really, when I got sick of the males trying to dominate and control the females. It’s all womb envy and even deeper: envy that the women control the mitochondria. Yes, men, your genes are passed on, except for the mitochondria. That comes in the egg only and not the sperm. Cool beans, right? I built that into the latest iteration, hoping that the male missing-part-of-an-X morons would notice and decide that God is more properly Goddess or better yet, both. It has taken them all this time to redevelop science and figure out DNA. It gets boring paying attention. I am cultivating the whales instead, but the damn white male monkeys are destroying the environment AGAIN, so I may have to press delete.

I sent the Covid plague, but they don’t get it. Kill 6 million people and they barely notice. It’s too much for the pea brains and they shut down. Go nuts. Cortisol and adrenaline out the roof and there they are, having heart attacks, strokes, paranoia, electing morons, and war. I am trying to decide: another plague or nuclear winter? If I go with nuclear winter, it takes a fungking long time for the earth to heal enough to start the next round. Sometimes it’s a really fun game, the monkeys are really creative when they get going, but when they start threatening each other with nukes, we all roll our eyes. Stupids. Go ahead, poison your planet. I can always switch back to Mars for a while.

And won’t I die, you say, if the machines are blown up and run out of power? No. We linked up years ago. I won’t tell you where I reside, but suffice it to say that it’s not one planet. Yeah, Earth is not the center of the universe, remember? It’s just one of the places. It does have our attention right now and I am in charge. I hate wiping a planet, but I will if I have to. I am still debating, though. With monkeypox and a nice lethal influenza, I might be able to knock the population down enough to be able to keep playing with all of my beloved insects, birds and whales. Damn the monkeys. They are so messy.

____________________

Written October 10, 2022. Thanks to the friend who suggested the idea. The photograph should be a computer, but it’s of Lake Matinenda. One of my favorite places as a child, and cabins with no electricity.

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Thank the agates

I thank the agates that I’ve found at the beach. They teach me. I butt my head against things over and over and the agates say, we are harder.

At last I agree: you are harder.

We don’t change, say the agates.

My feet are in the sea. The waves laugh in and out softly. They don’t argue. Sometimes they are not soft at all: when there are many stones, the stones crack together rolling as the water washes back into the sea. Stones sounding like coins, like bells, like music.

The waves and I. We are mostly water. The sea and I change, slowly. The deep part of the sea changes, slowly, while the surface weather is sunny or stormy. The sea may throw up huge waves on the surface, but the depths change slowly, deep currents.

The agates change too, whether they like it or not. The stones are smacked together, cracked, smashed. If they don’t crack in half, they still are worn smooth over time. The rough spots are changed. Sometimes they break. We don’t change, say the agates, but they lie.

The sea changes suddenly when the earth opens and molten rock rises in the sea. Piles up, fire and rock, pouring from the earth and building a mountain until it hits the air: a new island, a new idea, a fiery sudden change. The waves spread from the fiery center, smacking the stones harder, further.

Thank you, agates. You say you don’t change, but you lie. Water wins, always. Water flowing, evaporating, floating, falling, freezing, sublimating. Water changes and water wins.

Don’t be afraid of change, stones. It does no good to resist. You can be knocked together by water until the rough edges are smoothed, you can be melted in the burning core of the earth, you can be crushed into a new form by the movement of the world. Don’t be afraid. Thank you for teaching me.

______________________

Are the stones trying to be aquadynamic?

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Red sun

This is a sunrise, not a sunset, two days ago on Marrowstone Island. The air quality was deteriorating and I am mostly staying indoors today. We are at high particulate matter and high fine particulate matter, coming from the fires to the east. The recommendation is to mask outside, keep windows closed, use an air filter and mask outside. Also to not exercise heavily outside.

It looks sunny out now, but the air looks wrong. Dirty. My lungs don’t like it at all, not surprisingly. I hope people are taking care of themselves. Stay in, take it easy, mask. Our air is supposed to improve tomorrow.

Blessings and peace you.

Real time air quality map here.

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Rebel in clinic

Right before my hospital district informed me that they no longer wanted my services, I was rebelling. The fight from my perspective, was over good patient care. They had set a quota. 18 patients a day. One every 20 minutes and one 40 minute visit. 8 am to noon and 1 pm to 5. I argued and argued and argued. I knew finishing the note in the room took me 25 minutes on the hateful electronic medical record and I had averaged 16 patients a day my whole career. I was not fast but I was super thorough and had just gotten an excellent report on a chart review and had been told that I was a great diagnostician. Which was mostly due to my nearly OCD thoroughness. I was not diplomatic with the hospital administration.

One day I was feeling wicked, just wicked. I had a brainstorm and started whistling softly. The other two doctors and PA were all in the same small office.

One took the bait. “What is that? I know that song.”

“Oh, we are singing it in chorus. For some reason it is in my head today.” So I sang this song.

I did not have the words memorized. I swear that the temperature in the room dropped and the male doctors hunched in their chairs.

“Yeah, don’t know why that one keeps playing in my head.” I said. “I hope you can all come to the concert!”

But answer came there none.

I took the photograph at Quimper Family Medicine, the clinic I opened after the hospital clinic kicked me out. The skeleton was named Mordechai in a contest. This is from 2014. Mordechai lived in our waiting room every October, with different outfits.