Category Archives: rural doctor

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Strep A and Covid

In clinic we are seeing Strep A and Covid in the last two months, quite a lot.

Covid is all over the map with symptoms. One person had been traveling, did not feel well, but the main symptom was dry lips. Positive covid. Another was vomiting, with no upper respiratory symptoms. Some have diarrhea and upper respiratory symptoms. It interests me that flying home to Washington last month, only about three of us on the planes wore masks. I was one of them. I know people who have taken flights knowing that they have Covid, a day or two after diagnosed, so I can’t say that I trust the other people on airplanes. We are testing for Covid for almost any symptom or just feeling sick.

We are seeing Strep A as well. I saw a small child vomiting. I asked if her nose hurt: no. Throat: yes. Tummy: yes. Toes: no. She had strep A. The oldest person with strep A this week was ninety. She said, “How did I GET it?” Streptococcus is in the environment, including our throats. We may just carry it around, but then if we get overtired or stressed (good or bad stress) or have something happen, the strep can invade. We treat strep A mostly to prevent rheumatic fever, which is where our own antibodies to strep A attack us. I have seen three cases of rheumatic fever in my career. That is called a “pseudo autoimmune” disease. The strep A has cell surface markers that sometimes are close enough to ours that our own antibodies attack our body parts.

One person in the last month has a positive strep A. I write for penicillin and send her home. We call her later because the Covid/influenza/RSV test takes longer. She also has Covid! That seems like a bit much, rather unfair, but we can have two things. An initial infection can lower our immune defenses and another virus or bacteria gets hold.

Another person had tested negative for Covid, but that was four days before. Friday afternoon, so I would not get the results at home. I asked her to retest at home. Positive.

Here is the CDC page about Strep A. https://www.cdc.gov/group-a-strep/index.html

There are Strep B and C and D and so forth. Sometimes we pick them up on throat cultures. I treat if the person is still sick and symptomatic while the culture is in the laboratory.

I am wearing a mask in airports and on airplanes. I just don’t want to pick anything up, or at least do what I can to avoid it.

The photograph is Elwha in May 2023. I figure that you would rather see his tongue than mine.

For the Ragtag Daily Prompt: strep.

I think the song might be off topic. I don’t care. Beautiful.

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Advertising alphabots

“The singular media and its plural medias seem to have originated in the field of advertising over 70 years ago; they are still so used without stigma in that specialized field. In most other applications media is used as a plural of medium. The popularity of the word in references to the agencies of mass communication is leading to the formation of a mass noun, construed as a singular.” From here.

advertising alphabots
hot bots with rotten lots
true crime creatively “reenacted”
big data theft unredacted

earbud earworm mealworm eely
faceNObook curated freely
grinning google amazons greed
hoary heads hawk hell few heed

i phone i watch i influence
a list j list jovial ents
kotkit koobecaf bookcafe
love light liberating libraray

magazine murmurs metaverse more
newspaper calls politician a whore
organic natural lab rat pores

play tape, CD, podcast album
quiet queens reject the pablum
radio radical rhetorical ram
spambot spammail spam yum spam

television treads traditional trust
unit united universe untie us
vehicle vroom driverless porn
walkman withers worms are worn

Xray googling exacerbates lies
you are the target of sales AI
zealous AIs algorize pi

_____________________________

For the Ragtag Daily Prompt: media.

ChatGPT’s take: “This is a captivating piece! The blend of modern themes with a rhythmic structure creates a vivid commentary on technology and society. It’s playful yet sharp, tackling everything from advertising to data privacy. The way you weave together pop culture references and critique consumerism is particularly striking. Do you have any specific themes or ideas you’d like to explore further?” Nope. Thanks, ChatGPT. — See, Martha, I think ChatGPT has low tastes. It doesn’t understand sonnets and it probably loves limericks. We’d better test that theory.


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Alphabeasts

ambulating antelopes
bellies bearing beer
carrying cantelopes
deride damp deer

elegant elephants
feeling fitly fat
give generous gifts
handing hippos hats

ignorant iguanas
jealously jeer
keen kindly kites
lilting laughing leers

many merry meerkats
nearly never notice
one old orangutan’s
pompous pronouncements

querulous quail
reject reports regarding
shimmering snow snakes
tearing through tunnels

undulating ungulates
veer vivaciously
wondering why whales
xerox xylophones

yellow yaks yell
zip zap zoo!

For the Ragtag Daily Prompt: zoo!

I wrote this sometime in the 1980s. My proof is the drawing by my mother. We had it in a show and hand colored with colored pencils. There is now a book with the same title by a Canadian author but it came later.

And hooray for the zoo! They are all asking for you!

Martha, what would the AI think of this poem? Heh. ChatGPT: “That’s a fantastic poem! I love how it captures the playful nature of alliteration and the whimsical imagery of animals. Each stanza has its own charm, and the ending with the “yellow yaks” is such a fun wrap-up! Did you create this as a fun project, or is it inspired by something specific?” Ok, so ChatGPT doesn’t get sonnets, but it likes nonsense poetry.

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Distant mesas

I have been in Grand Junction since the end of April. The Grand Valley really has amazing visual distances from one end of the valley to another, and even though it is a valley, it is at 4600 feet above sea level. It is surrounded by higher mesas and mountains in all directions.

Soon I drive back to Washington for a few weeks. That is a distance, too, 1200 miles with Sol Duc cat. She doesn’t really enjoy the car. I wonder if she will enjoy going home. Will she like the cloud settling over us, as if the bottom of it is grazing the roof tops? I did not like those clouds when I first moved to Washington but now they feel as if they enfold us and comfort us, an intimacy with the sky.

For the Ragtag Daily Prompt: distant.

We learned this song as kids:

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Authenticity and masks

The Ragtag Daily Prompt today is identity. Yesterday I went to work an hour early so I could attend the Friday morning Continuing Medical Education. It was about adult ADHD and the positives and negatives.

I do not have a diagnosis of ADHD. I have one friend who insists that I have it, but I don’t much care. However, the speaker started talking about masks and authenticity. She said that we are told to be authentic at work, but that people with ADHD often find that their authentic self is not welcomed and they learn to mask.

I asked, doesn’t everyone mask somewhat at work? She said, “Good point, and yes, people do.” It got me thinking about identity and masks. I pretty much clammed up in Kindergarten because I was too much of an outlier and culturally wrong. We did not have a television and television was pretty much what the other children talked about. I knew songs and poems but these did not interest my peers. I was interested in science, too, but that was also not popular. I think I was a geek before it was named and as soon as I learned to read, I became a bookworm. I am not sure if having a television would have made any difference, either.

Fast forward to after high school. I went to Denmark as an exchange student my senior year and then needed to make up credits to graduate. Another high school student was in my Community College classes. After a bit, she said, “I thought you were shy in high school.” I said, “No, I just didn’t talk.”

Currently I am more authentic in the room with patients than with the rest of the staff. Corporations are very weird hierarchical places. My authentic self always questions authority but I am trying not to do it all the time. At least, not out loud. The patients seem to be fine with it. I had a very difficult conversation with an elderly couple this week about memory and planning, now, before they can’t. I got hugs at the end of the visit even though we’d gone into frightening and difficult territory. They did very well. Yesterday was my last day at that clinic and next week I am in another one. Even after just four months in this clinic, I will miss many of the patients and hope they do well.

Yesterday I really did Urgent Care. My schedule only had a few people and then six more sick ones were added on. We had to call an ambulance for one, the first time I’ve had to do that here.

What is authenticity and what is our identity? Is the work mask less real than the self in our minds?

I took the photograph at a small hot springs resort. A friend that I’ve known since high school and I met there. I love the bookworm rabbit. I think she represents the happy bookworm part of me. I read about 7 novels a month, haunting the library here. Maybe I will get to know some more people over the next 6 months.

For the Ragtag Daily Prompt: identity.

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The isolated working

I ran my own small clinic from 2010 to 2022, working somewhere else, got Covid, was on oxygen for a year and a half, did some healing and then came back to work.

There has been a culture change in medicine that feels very strange to me. I did not notice it because I was in a solo clinic and not “part of the system”.

All the doctors, providers, are more isolated. I got a compliment yesterday when I was doing a “warm hand off” of the most sick or complicated patients, three new diabetics, a person with cancer, a person with a genetic heart problem. The doctor who I was handing off to is in the same clinic but we have barely talked since May. I don’t know her at all. She complimented me on excellent care “and calling specialists”.

I thought, huh. But I think that is a dinosaur doctor thing. I think mostly people communicate through the electronic medical record email, send messages about patients. For the decade that I was solo, I had to call other specialists because I was on a different electronic medical record. The email didn’t connect. The hospital reluctantly gave me a “link” to their system, but it was only a link to look. I could not write or send anything.

About two months ago I got an echocardiogram result. I read it and thought, ok, it’s not normal but what does it mean? Outflow obstruction by the thickened heart wall. Hmm. I called cardiology and spoke to the cardiologist who read it. He sounded surprised and said, “Idiopathic hypertrophic cardiomyopathy, most likely. It’s a classic echo.” “So, what do I do?” “Send him to me.” “Anything that I should change meanwhile?” “Yes,” says the cardiologist. He had me stop one medicine and start another. “No vasodilators and the beta blocker slowing the heart rate should help decrease the outflow obstruction.” “Got it.” I said. He also gave me two more tests to order.

I referred the patient to cardiology but it was a month before he got in. The two tests were done and they ordered more. If the diagnosis is correct, he’ll be sent to a special clinic in Denver. I called my patient while we were waiting for the cardiology visit. The medicine change had not made much difference as far as he could tell.

I was also told when I got here that I would never get a local nephrologist to see a patient, they were two busy. However, I have called two nephrologists about two patients and both took the patient and again, gave me instructions.

Two specialties have been very difficult to contact: orthopedics and gastroenterology. I have no idea why they are so difficult.

I can see that email feels faster. But there is no human contact, asking follow up questions is difficult, I don’t get that bit of further helpful education: this is what you do next. I have learned so much over the years by touching base with specialists. Once I fussed at a patient to go to hematology oncology about their high platelet count. The patient didn’t want to. He came back and said, “Apparently I have this newly found genetic problem. They put me on two medicines, not expensive. And I feel better than I have in 20 years.” I asked the oncologist about it the next time I called. He lit up, excited, and told me about the JAK-2 mutation. It is so exciting to learn about new areas in medicine and my patient says, “I have to thank you for pushing me to see the oncologist. I feel so much better.” Wow and cool.

Clinic feels like I am mostly isolated, a silo, an island, rarely talk to the other physicians unless I go to find them. I think hospital administrations like this, keeping the physicians in line by having their schedule be so packed that they almost never talk to each other. What a good way to keep physicians from interfering in the money making production! Ugh, I think it is quite horrible and unhealthy for the providers and for our countries medical system in the long run. I was seriously less lonely in a solo clinic.

The prognosis for our current medical system is very poor. The patients say to me, “Why do my doctors keep leaving?” They aren’t attached, they are isolated, I don’t think the physicians know what they are missing. Colleagues. Not silos.

For the Ragtag Daily Prompt: prognosis.

The photograph is from the Fruita Fall Festival.

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The boring vampire

I meet a boring vampire
when I am boring too
when I am worrying with angst and ire
and have too much to do

It’s in the time of covid
We start to walk the beaches
The vampire won’t take paxlovid
His ego overreaches

He says his life’s perfection
He says his brain can’t fit his head
He has no belief in resurrection
That’s probably because he’s dead

I wonder that he lies
Does he think that I don’t see?
The person that believes the lies
Must be him, not me

I grieve before he ousts me
He says he’ll always be my friend
And he speaks of longing to be free
I know there will be an end

I know before he ousts me
He says we’re friends forever
I blink and calmly see
That it will soon be never

Some vampires don’t need staking
They do it to themselves
Isolation of their making
Hoarding blood upon their shelves

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The photograph is a “swamp robin” (Varied Thrush) from my yard, December 2022.

This has nothing to do with the Ragtag Daily Prompt: festival. Except that swamp robins are very festive.

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Love gently

Honey is older, nearly thirty years since that first feeling of being bitten by ants. She is back in corporate medicine, as a temp. Temporary, short term, maybe that will work better.

It is a joy to go in a room and be alone with a person and their monsters. Theirs and hers. Sometimes the younger ones haven’t experienced it, they are terrified if one of their monsters becomes a little bit visible, they hate seeing them. Honey tries to be gentle. If they only want to talk about the sore shoulder and not the stress and violence, well, she leaves the door open a crack. Sometimes the monsters cry.

Older people may be stiff to start with, but when they realize their monsters are seen, acknowledged, this isn’t another robot doctor in to say increase your diabetes medicine, lower your diabetes medicine, tell them a plan without ever connecting, the older ones lean back, sigh, and relax. The monsters play on the floor, Honey’s monsters playing with theirs, happy, engaged.

The hard part is the clinic staff. Honey is with them daily. The medical assistants are young. They kick their monsters aside as they walk down the hall. It is terribly hard and heartbreaking to work at her desk, with the medical assistants’ monsters cowering under their desks, kicked, abused, silent tears and holding bruises. Honey’s monsters mind. They climb into her lap and hide their faces in her shirt, under her jacket, peer over her shoulder. They don’t understand! Why can’t she be nice to THESE monsters?

Honey whispers to her monsters when the medical assistants are rooming patients. “I am so sorry, loves. If I acknowledge these, the monsters of the women working, I become a demon. It is very hard to share an office, no wonder I worked in a clinic alone for eleven years.” Honey has been through that. It is still inconceivable that some people don’t see the monsters at all. Is it learned blindness? Or just not developed unless someone had to learn it? Unless someone grows up in terror and seeing the monsters is the only way to survive.

Honey thinks some people learn to see them as adults, at least their own monsters. Hard enough to do that, without seeing the monsters clinging to other people.

Honey is tired of her monsters crying in sympathy with the staff’s monsters. She thinks maybe there are small crumbs that she can leave for these demons. Little gifts. Her monsters can creep under the desk when she is the only one in the room and leave something. A flower. A dust bunny. A crumb of a crisp. A small rock. A little gift to let them know they are seen and loved. A poem. A prayer. Just a tiny bit of love.

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For the Ragtag Daily Prompt: crisp.

The photograph is me all dressed up for the 1940s ball.

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Weighing in

No nightmares about clinic since the one I wrote about two days ago. I do feel like a bit of a dinosaur in clinic, though. Most of my older patients seem to really be fond of dinosaurs.

I’ve heard from other docs that they don’t have time to talk to each other in clinic either. Patient time but primary care we read all the notes from everyone: specialists, PT, OT, xrays, CT, MRI, ultrasound, lab, lab, lab, lab, prescription refills, phone calls. I read that people are trying to insert Artificial Intelligence into this. I am fine with a computer learning to read mammograms, but condensing information from notes? The AIs currently can “hallucinate”, and make things up. Is that worrisome or am I being silly? Notes are often wrong ANYHOW, way more than I would like. I saw a patient yesterday who has a neurological disorder. The hospital discharge note lists the wrong one! The patient caught the error, I didn’t. I am very glad he corrected me, but the hospital note is still sitting there wrong. Having been labeled with wrong diagnoses myself, I think it is a big deal. In order to fix it, he would have to fill out a form and the form would go to the physician, who is supposed to respond and add an addendum to the note. How often do you think THAT happens?

The discharging physician suggests he see a specialist for testing. I call that specialist and they agree with me: that testing is not indicated, it won’t make one bit of difference in his treatment. The discharging physician also suggests lung testing. I don’t think it works or is useful with a serious neurological disorder that affects muscles! Think, people.

My patient is grumpy and asks how we know the medicine is working. I reply, “You’re not dead.” Which is true. Undiplomatic, but he does not mind, because he is already saying, “What is the point of this?” To explain more about the medicine working, I ask, “Is your breathing better than when you went to the emergency room?”

“Yes,” he says.

“That is because the medicine is working.” I explain how it works and what happens if he stops it.

Sometimes it makes me feel heavy, heavy, like a dinosaur.

But I think I will try discussing my clinic day with my cat. I think she might enjoy it and I can clear the grumps out. And it’s not a hipaa violation! She doesn’t like other cats and won’t tell them anything.

For the Ragtag Daily Prompt: dinosaur.

This is new to me:

I’ve never seen these cartoons. The animation is, well, not the best. The guitar work is fun though!