Category Archives: rural doctor

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flight

Cormorant, I think.

About to take flight.

A good take off point.

It takes five years for bald eagles to fully mature. This one is close.

And a great blue heron in flight in the fog.

For the Ragtag Daily Prompt: flight.

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Covid-19, Long Haul and the immune system

“Whether immune-mediated secondary OCD could also develop as a consequence of COVID-19 poses a highly relevant research question to be elucidated in the near future [35, 36]. The first studies of their kind have demonstrated infection-triggered neuronal antibody production against various antigens in COVID-19 patients who were presenting with unexplained neurological symptoms [37].” from https://www.nature.com/articles/s41398-021-01700-4

Um, yes. It is looking highly likely that chronic fatigue, fibromyalgia, and Long Haul Covid-19 are all immune system responses. They are not simple at all. They can involve antibodies, cytokines and killer T cells and probably other things.

Antibodies: the difficulty here is that we all make different antibodies. It’s all very well to say that people with PANDAS and PANS make antibodies to Dopamine 1 and 2 receptors, tubulin receptors and lysoganglioside receptors, but people each make different antibodies. The antibodies can attach and block the receptor or can attach to the receptor and turn the key: act like dopamine, for example. Dopamine makes people tachycardic, a fast heart rate. If dopamine receptors are blocked, that could be a source for “brain fog” and feeling down.

Cytokines: I worked at the National Institutes of Health back in the 1980s before medical school. We were studying interleukin 2 and tumor necrosis factor for cancer treatment. Building 10 had mice on the north south axis and human patients on the east west. It was fascinating. Now I am reading a current book on the immune system. There has been a lot of research since 1988. Cytokines are released by cells and are immunodulating agents. They are a form of communication in the immune system.

Killer T cells: When antibodies coat a cell, there are immune system cells that kill and/or eat the coated cells. This is good if it is an infectious bacteria or a cell infected with virus, but it is bad if it is your own joint cells or your heart cells or, horrors, brain cells. In rheumatic fever, antibodies to strep A attack the patient’s own cells as well as the strep A cells. This is called “pseudo autoimmune” but I am starting to suspect that all the autoimmune disorders are responses to stress or infection or both.

So if you are still reading, you are saying wait, this is awful, what can we do about it?

Our understanding of the immune system is better than 1988 however… it still has a ways to go. I think that Covid-19 and Long Haul Covid are going to seriously accelerate the research in this area. Meanwhile there are some things people can do to “down regulate” or quiet down the immune system.

If antibodies are causing some of the problem, we need to quiet them down. With severe PANDAS in children, plasmapheresis filters the blood and filters out antibodies. However, the body keeps making them. Infection must be treated first, but then the initial antibody response lasts for 6-8 weeks. Then the body makes memory antibodies and cells to remember. With reinfection, the response lasts for 2-4 months and then subsides if the infection is gone.

Treat infection first. Then treat urgent symptoms, including urgent psychiatric symptoms. Then work can start on the sympathetic nervous system, quieting down to the parasympathetic state. This is not easy with Long Haul Covid-19 or chronic fatigue or fibromyalgia because people are afraid, confused, in pain, exhausted. I have written about the sympathetic and parasympathetic nervous systems here and here. Start with slow breathing, four seconds in and four seconds out. It takes practice.

I have been getting feedback at the pulmonary rehab. When I arrive, they take my pulse, 02 saturation and blood pressure. They put the pulse oximeter on and often I am up in the 90s. I slow my breathing and watch my pulse drop. One day I came in relaxed and my initial pulse was 71. When I was a little late, it started at 99 and came down. The therapist took it off when I got my pulse down to 90. We can check our own pulse, the number of heart beats in one minute, or a small pulse oximeter is about $30.

We can’t really “fix” the immune system with drugs. Steroids can quiet inflammation but they make us more susceptible to infection and raise blood sugar and cause multiple problems when used chronically, like osteoporosis. Plasmapheresis is expensive and requires specially trained nurses. Doesn’t a breathing exercise sound a lot more DIY and cheaper too? You got this. Practice, practice, practice.

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Care bare? No, Care Barrier.

My cardiologist told me to go to the Mayo Clinic six months ago.

I saw him last week and he wanted an update.

I said, “I filled out a request for a visit and my primary care referred me, but Mayo Clinic never called.”

He replies: “I will refer you.”

A week later I get a call from Mayo Clinic. But I do not have an appointment yet because

  1. They are booked out until November 18th. I am advised to “call daily” to get my appointment. They open up a week at a time, but don’t say when. A new meaning to “maybe you’ll get lucky”.
  2. They do not take my insurance and want a $5000 deposit prior to seeing me. I can fill out paperwork to ask for patient assistance. This would be the fifth hospital system in which I have filled out that paperwork. I have had to do it for four other places. The paperwork is different for each one and some even want a copy of my taxes. Do you think it’s secure? Of course it isn’t.
  3. I have to go in person to Minnesota, so add a round trip plane ticket to that $5000. They may do tests while I am there, so I don’t know how much of the $5000 I would get back. If any.

At the moment this seems insurmountable, but I will keep chipping away at all the insane barriers and paperwork. What a stupid medical system the US has, right?

We still need single payer and medicare for all. There would be one set of patient assistance papers, not five.

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Autoimmune OCD and my daughter shops my closet

https://www.nature.com/articles/s41398-021-01700-4

The article is a proposal for diagnostic criteria for autoimmune obsessive compulsive disorder, a relatively rare version of OCD. Important because the treatment has to include searching for infection that triggers the antibody response, which in turn attacks the brain. Antibiotics to treat a “psychiatric” disorder. Mind and body connection, right?

The ironic thing about this new proposed diagnosis is that I do not have obivious OCD in any way, shape or form. It is masked by packrat. Also, my OCD is focused. When I was working, it was focused on patients. My clinic charts were thorough, 100% of the time. I was brutally thorough and wouldn’t skip anything. The result was that I got a reputation for being an amazing diagnostician. Usually it was because I wanted ALL the puzzle pieces and the ones that don’t fit are the ones that interested me. They have to all fit. Either the patient is lying or the diagnosis is not as simple as it appears. Occam’s Razor be damned, people can have more than one illness.

In fact, an article 20 years ago looked at average patient panels and said that the average primary care patient has 4-5 chronic illnesses. Hypertension, diabetes, emphysema, tobacco overuse disorder, alcohol overuse disorder, well, yeah. And then the complex ones had 9 or more complex illnesses. You can’t see the person for one thing, because if the diabetic has a toe infection, you’d better look at their kidney function because the antibiotic dose can kill their kidneys if you don’t adjust it. So do not tell me to see the patient for one thing. Malpractice on the hoof. Completely crazy and evil that administrators tell doctors to do that.

No one looking at my house would ever think I have any OCD. I am not a hoarder (ok, books) but the packrat force is strong in me. My daughter did not inherit that gene. She is a minimalist. However, she has come to appreciate the packrat a little.

This summer she said that her purse is wearing out. As a minimalist she has one purse. I ask, “Would you like to see if I have one that you like?” It so happens that as I was trying to recover from pneumonia, a local garage sale had 20+ year old designer purses for $3 each, because the house was going on the market. Got to get rid of the stuff.

“Yes, please.” says my daughter.

I start with the weird ones that I know she will not want. I get eye rolls. But I am progressing towards the purses that are close to the one she has. At last I produce a small leather purse, the right size, in good shape, and she sits up. “Let me see that one.” Like Eeyore with his popped balloon, putting it in a jar and taking it out, she tries putting her phone and wallet in the purse and taking it out. “Yes, I like this!” She calls it “Shopping mom’s closet.” I think it is delightfully comic. The benefits of a packrat mother.

Back to the Nature article and OCD. The diagnostic criteria are gaining steam. Having watched a conference this summer about Pandas and Pans, mine is mild. Some young people have a version where killer T cells invade the brain and kill neurons. I had a moment of panic when the conference was discussing a case, but then I thought, if I had the neuron killing kind I would be dead or demented by now.

Instead, I’m just a little neurologically unusual.

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Healing

I realized I had pneumonia for the fourth time on March 20, 2021. It has been a year and five months now. I do not have an “overarching diagnosis” for why I am so vulnerable to pneumonia, though not for lack of trying. I have seen twenty specialists since 2012, including four pulmonologists.

Most specialists dismiss me as soon as their tests don’t fit me into one of their boxes.

I have one now who is not dismissing me. He referred me to the Mayo Clinic. They did not call back when I did a self referral three months ago nor when my primary care physician referred me. However, they called within a week of his referral.

Mayo Clinic called yesterday. I may need a prior authorization or something, I have a number to call today.

I am healing. I still am on oxygen for singing, flute, night and heavy exercise, but pulmonary rehabilitation is working. I have built up steadily on the treadmill for 6 weeks. I have 5-6 more. Many of the pulmonary rehabilitation people are on oxygen and will not get off oxygen, so I am an outlier here too.

I feel better than I have in seven years, since the 2014 pneumonia. I had strep A pneumonia in 2012 and 2014 and really did not fully heal after 2014. I was tired all the time. I think I went back to work too soon and just did what I could. Not returning to work is helping immensely. I can’t return anyhow, unless the Mayo Clinic or someone figures out my “overarching diagnosis” and how to make me less vulnerable to pneumonia. Seems unlikely after 19 years. My first round was influenza in 2003. Maybe choosing a different career than primary care would have made a difference, though maybe I would not have survived a pneumonia without being a primary care doctor. We aren’t supposed to treat ourselves, but if no one believes us, well, there is not much choice, is there?

The photograph is from a beach hike in November 2021.

For the Ragtag Daily Prompt: heal.

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the gang’s all here

Hale hale the gang’s all here
wrong hale, it’s a hale of a thing
but it should be hail
the same sort that falls from the sky

but on the other foot, hale hale
anyone who has survived the pandemic
is more hale than those who haven’t
so hale hale for the gang still here

For the Ragtag Daily Prompt: hale.

Let’s dance!

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pigeon guillemots

These are called sea pigeons locally.

We were trying to figure out who lives in the sand cliff holes on Marrowstone Island.

We see something fly out but weren’t quite sure who it is.

And then, aha! We see an owner.

https://www.allaboutbirds.org/guide/Pigeon_Guillemot/id

They look like ducks except the beak is not duck like. From the Cornell All About Birds Site: “Ornithologists recognize five subspecies that differ mostly in size: eureka in Oregon and California; adianta from Washington to the central Aleutians; kaiurka in the west-central Aleutians and the Commander Islands; columba from the Bering Strait to the Kamchatka Peninsula of Russia. The subspecies of Pigeon Guillemot that inhabits the Kuril Islands of Japan, snowi, has little to no white in the upperwing, unlike other subspecies.” They are in the family with auks and murres and puffins, rather than ducks. How aukward, heh, heh. I am informed that they “are not good eating”. Too fishy.

For the Ragtag Daily Prompt: float. They are very good at floating and diving, and make a whirring sound as they fly. They have a high piping song.

The range map is cool: https://www.allaboutbirds.org/guide/Pigeon_Guillemot/maps-range.

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Hello universe

You know what?

I want to get remarried. Add that, Beloved, to me wanting someone to love and to love someone.

Commit, damn it.

And that is what I now want. Thank you recent ex for showing me what I want.

I want to be myself from the start.

I want to notice bullshit and walk away before we get involved.

I don’t want to be controlled, I don’t want to control, I want a partner.

I don’t want to be enabled, I don’t want to enable, I want mutual respect and caring.

I am not your shrink, you are not my shrink, and if one of us needs a shrink, we should find one.

I want to notice lies and walk away before we get involved.

I want to speak up if you tell me lies, or I want to back away for good.

I want to be loved and I want to love. By the same person, damn it.

Hear my prayer, Beloved. Hello, universe. Here I am.

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Top ten causes of death, US, 2020, and doctor time pressure

https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

There is an article about US doctors, that primary care would have to work around the clock to apply all of the guidelines, here: https://news.uchicago.edu/story/primary-care-doctors-would-need-more-24-hours-day-provide-recommended-care.

Yes, but this is not new news. There was a trio of articles twenty years ago that said the same thing. And the guidelines have only expanded. Primary care is doing the same thing it has always done: what it can. Meanwhile we go to “Continuing Medical Education” and the other specialists ALL say we are not doing enough, we need to do more. Makes a woman cynical, don’t it?

Family Practice is a specialty, did you know that? We do a three year residency. Internal medicine is also three years, but many then “sub specialize” — further training in cardiology or rheumatology or nephrology, and etc. Sometimes we get a primary care doctor who doesn’t do the extra years but gets interested in something and they learn to subspecialize. We had a pulmonologist on the peninsula here, best I’ve worked with, who had not done the fellowship but learned it on the job. She was excellent and is now retired.

So you as a patient need to be aware of the top ten causes of death and do some thinking. Heart is still number one, in spite of Covid-19. All the cancer deaths are number two, but that’s only a fraction of the cancers. You want cancer screening, to pick it up before it is lethal. Pap smears, colon cancer screening, get your skin checked. Covid-19 is number three in 2020. Let’s look at the list.

US top ten causes of death, 2020.

  • Heart disease: 696,962
  • Cancer: 602,350
  • COVID-19: 350,831
  • Accidents (unintentional injuries): 200,955
  • Stroke (cerebrovascular diseases): 160,264
  • Chronic lower respiratory diseases: 152,657
  • Alzheimer’s disease: 134,242
  • Diabetes: 102,188
  • Influenza and pneumonia: 53,544
  • Nephritis, nephrotic syndrome, and nephrosis: 52,547

The list changes. What has fallen out of the top ten, since Covid-19 was not on the list back in 2019? “Intentional self-harm” aka suicide, was number ten in 2019.

Let’s go through the list one at a time and give you some basic tools and ideas about prevention, since your physician doesn’t have enough time to deal with all of it.

  1. Heart: The people who have not seen a doctor for twenty years, um, go see a doctor. If you have high blood pressure for twenty years, you will also have heart failure, which means pump failure. This is bad and will kill you. Check in at least every three to five years. In the US currently, you are a “new” patient after three years, so it’s best to show up just before that three year mark. Call ahead, everyone is short staffed. Check blood pressure, cholesterol and quit smoking (that includes pot, also bad for the heart), cocaine is very effective at trashing the heart, alcohol is bad for it, so is methamphetamines, and any other silly and stupid substance “overuse”. Kratom? Bad. Fake pot? Also bad. Turn off the tube or computer and go for a daily walk. Outside. Without headphones or earbuds. Try to figure out the bird noises, ok? Eat more vegetables. Don’t be stupid.
  2. Cancer: do the screening tests. Get the HPV vaccine for your children. Get pap smears. Use sun screen. Get your colonoscopy when you hit that age. Want to read about a screening test? Go to this site: https://uspreventiveservicestaskforce.org/uspstf/home . This is the clearing house for the current guidelines AND THEY CHANGE. They get updated. The vaccines are all here too. Get them.
  3. Covid-19. If you aren’t vaccinated then I don’t even want to talk to you, unless you are seriously immunosuppressed and your docs told you not to. Otherwise your brain has been taken over by non-scientist crazy whackos. IMHO.
  4. Accidents have been rising up the list and currently number one is opioid overuse deaths. Do not buy pills on the street because even if they claim to be oxycodone they may actually be fentanyl. The drug cartels aren’t so good at diluting the fentanyl enough to not kill you. If you are on prescribed opioids you should have a shot to reverse it (narcan shot or nasal spray) and your family or friends should know where it is and how to use it. Next is guns and cars. Guns should be locked up with the ammunition locked up separately when you are not working as a policemen or hunting a deer or rhinoceros. Cars should not be driven under the influence and hello seat belts. Oh, let’s see, wear your helmet on the bicycle, roller blades, e-bike, jet-skateboard or whatever. Wear a life jacket in the boat. Don’t point Axe towards your face and try to light the spray on fire.
  5. Stroke. This is all the same stuff as heart. And also Covid-19 increases your risk of stroke.
  6. Chronic lower respiratory disease: this is mostly caused by tobacco, tobacco, tobacco, marijuana, tobacco, asbestos, tobacco and woodsmoke or firefighting. Smoke is bad. Vapor is smoke, ok? See your doctor to get help quitting smoking. My father quit after 55 years of 2 packs a day of unfiltered Camels, so don’t tell me you can’t. Also it takes an average of 8 tries or so to quit. Yes you can.
  7. Alzheimer’s: keep your brain active, eyes are important, ears are important, eat those vegetables and if you live where I do, vitamin D in the winter.
  8. Diabetes: sweet drinks are bad. Fake sweet drinks are bad. A coke has 32 grams of carbohydrate. A Starbuck’s mocha 12 oz has 60. Quit drinking sweet drinks. Your goal is no more than 15 grams of sweetener a day. Now, what exactly is a carbohydrate? It’s anything edible that is not fat or protein. However, there are lots of very low carbohydrate vegetables out there. A cup of kale only has 8 grams of carbohydrate. Sweet peas and sugar beets have a lot more. Diabetics and everyone else should have at least half of every meal be vegetables, green and yellow and orange. Fruit is sweeter and all of the portion sizes (except kale) are less than you’d like to eat. Prevention is good.
  9. Influenza and pneumonia. Get your flu shot. There are two pneumonia shots and the first is given at age 65 and the second at 66. Except in people with heart or lung problems, then they get the vaccine early and repeat at 65 and 66. I think we are going to have a group of people who always mask on planes. I am one of them.
  10. Nephritis and etc. This is kidneys. What can affect your kidneys? Pills and illegal drugs, mostly. All pills that are absorbed are metabolized (which means broken down) by either the liver or the kidneys. Kidney function goes down slowly over a lifetime with age. We are seeing a huge rise in kidney problems because of too many pills. Yes, supplements too. Natural does not mean safe and what the heck is natural about a pill anyhow? Take as few pills as possible. Take ALL the pills to show your doctor. Ok, your doctor might be clueless about supplements. We had one person nearly hit the liver transplant stage until she showed my partner her supplement’s new label “Can affect the liver.” Holy cow. Should say “Can kill you.” So back to prevention: my baseline was that people should have blood lab basic testing every five years before age 50 and every three years after that if they were on NO PILLS. If they are on ANY pills, I recommend yearly testing. Did you know that the supplement companies can change what is in the pill at any time without telling you? Isn’t that reassuring? Heck no.
  11. There are still a long list of other causes of death. Liver disease, intentional self-harm, and on.

Since your doctor does not have time to think about all of this every time you stop by, it’s partly up to you. I don’t trust Dr. Google at all, but the sites I go to are the CDC, the Mayo Clinic, NIH, AAFP (American Academy of Family Practice). I look at lots of quack sites too, to see what is being sold, but I am not advertising them!

Be careful out there.

The photograph is Elwha watching the four point buck and wondering if it will eat him or not. From last week.

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teen toys today

Um, you say, these don’t really look like toys.

I had friends visit last week. These are the thirteen year old’s toys: he enjoys fixing cell phones and computers and asked if we had any old game platforms. I talked to my son and the thirteen year old is taking the ones he wants. And what was he working on in the picture? Replacing the broken glass in my cell phone.

Now many of you are jealous and would like this teen to visit you. My cell phone has a lot of parts and many tiny screws. There was only one left over and the phone is working fine and the glass is unbroken! Wow! Toys of mine that were used in explorations and repairs included my vacuum and I provided the super glue.

I thanked him with a comic book subscription, since we share an enjoyment and appreciation of comic books.

One of the most useful toys I had growing up was a china doll. Useful you say? Yes. We sewed doll quilts and doll clothes and made our own furniture and hoped for the tiny books in the Cracker Jack boxes. How is this so helpful? Surgeons asked where I had learned my stitching techniques. It was quite delightful to reply, “Doll clothes.” It really did help. I made one old fashioned dress with miles of ruffle, all hemmed by hand. In the 1970s I was embroidering my jeans and adding studs and we dyed t-shirts with melted paraffin and crayons. My sister and I nearly burned down the kitchen once, but we did learn which techniques to use to stop wax fires.

I am not sure who made this dress for the doll. My grandmother Katy Burling sewed doll clothes for us and helped us make patterns and nine patch doll quilts. My other grandmother Evelyn Ottaway could knit the tiniest doll clothes on knitting needles: I still have some of those as well. A tiny stole knit out of a furry yarn and lined with brown satin. My mother was an artist and loved crafts as well but NOT sewing. Pottery yes, sewing no.

My daughter promptly illustrated her lack of the packrat gene by putting half the furniture and stuff away and having a spare and elegant doll house. She learned to sew but does not like it much to date.

What childhood toys and ideas contributed to your adult skills?

For the Ragtag Daily Prompt: toy.