Category Archives: rural medicine

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plane view

I took this last month when I flew to Michigan for an almost brother’s birthday. He turned 50. The rising sun was just amazing and I could see the mountains beautifully. Yesterday’s photograph was also from the plane. I flew from Seattle to Chicago. In Chicago I took a taxi to the train station. There I waited for a train for four hours and then rode up into Michigan. It was my first real journey with the oxygen concentrator. My carry on had the concentrator, three back up batteries, my camera, a laptop and phone and charging cords for all of them. A heavy bag and I had to pull out laptop, batteries and camera at security. Fun, eh? But I had enough oxygen for a 12 hour journey and could plug in on the train. I could have plugged in on the plane too, but the cord was in the overhead compartment. Anyhow, it worked. Oxygen tubing, N95 mask and second mask over the N95… whew.

I also learned that I need to let the airline know 48 hours in advance that I am traveling on oxygen. They tend to seat you by a window so no one trips over your tubing. Though I was in an aisle seat on the way back. Anyhow…. made it, hoorah!

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Covid-19: simplified self care

  1. I am a Family Practice Physician for 30 years. I have had pneumonia four times. I last got pneumonia on March 20, 2021 and I am still off work and on oxygen. This is the first time I have been on oxygen. No tobacco, no marijuana, no lung disease found to date but my mother had tuberculosis when I was born and my father smoked unfiltered Camels. With the hospital beds filling up, this is to help keep people out of the emergency room if they don’t need to be there and to help people track how sick they are.
  2. Learn to take your pulse. You need a second hand. Your heart rate is the number of beats in 60 seconds. Take it at rest (which means sitting or lying down). Then try taking it after you walk. It should be regular unless you have known atrial fibrillation. Also, if you are fifty or older, you may skip some beats so that you have early or late ones. That is not worrisome.
  3. Normal is 60-100. If you are very out of shape, you might go up to 120 after you run up the stairs or walk fast.
  4. If your resting pulse is 120 or higher, call your physician. If you are very short of breath with that or your lips are turning blue, call an ambulance right away.
  5. If your resting pulse is normal, say, 70 beats per minute, and your pulse after walking goes up 30 points or over 100, you are sick. If you are very short of breath after walking you may need oxygen. Call your physician and walk… really… slowly. When your lungs are swollen, there is less air space to exchange oxygen and your heart makes up the difference. If your heart is beating at over 100 for long, it is like running a marathon. Don’t stop walking completely because you are at risk for blood clots. But walk really slowly.
  6. If your resting pulse is normal and your walking pulse is ok, try a loaded walk. Carry something that weighs 20 pounds if you can. Then sit down and check a pulse again. If it is over 100 or jumps 30 points, you too have lung swelling, it’s just a little more subtle. You need to rest too.
  7. With practice, you will have a good idea what your pulse is before you do a formal count.
  8. You can use a pulse oximeter but you have to use it accurately. The fingers should be not moving and lying on the person’s knee or table or something. Otherwise it will give inaccurate readings and scare you. With a regular heart rate, look for the light to be picking up regularly before you believe the oxygen level. O2 sats under 87% need oxygen, but also if someone is going below 95% or is a child, call doctor or ambulance.
  9. Take a multivitamin. It is a lot of work for your heart to race fast. Rest, rest, rest. I have had 4 rounds of pneumonia with lung swelling. It took two months, two months, a year and this time I am five months post pneumonia and still on oxygen.
  10. Don’t use quack supplements and don’t take veterinarian ivermectin. Hello, you are not a sheep.
  11. Remember that if someone is hypoxic, they may act goofy, happy and unconcerned or be scared or have memory loss or just be confused. I write really weird rhyming songs when hypoxic and have the poor judgement to sing them to my doctor.
  12. GETTING VACCINATED IS YOUR BEST BET TO NOT DIE OF COVID-19. AND WEARING A MASK ALL THE TIME AROUND OTHER PEOPLE.

Good luck and take care.

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do no harm

First do no harm.

That is part of the Hippocratic Oath and yes we did it at the end of medical school. “I will prescribe regimen for the good of my patients according to my ability and my judgement and never do harm to anyone.”

This is a pandemic. People are dying. A lot of people. I am not ok with people saying personal freedom, we don’t want to wear masks, we don’t want the vaccine. I take the oath to first do no harm: what about those people? They are putting their personal freedom first and do not care if they harm me. I don’t like them. Please don’t kill me. Please don’t kill my son or daughter or future daughter in law.

You can have your personal freedom not to wear a mask or get a vaccine: in your house. I don’t think you should be allowed off your property if you won’t put doing no harm to others first during a pandemic. Stay in your house. Don’t come out. It is selfish to put yourself and your personal freedom in front of multiple peoples’ lives. You can order from Amazon and order groceries and ok, you can associate with other selfish unimmunized unmasked people, but not the rest of us. Your personal freedom has a high chance of killing me. I am immunized but my immune system doesn’t work and I am already on oxygen. I don’t want to be around you. Stay away from me.

I think it is time for my community to give back to me and all the other first responders: medical, police, fire, grocery store, hospital, all the essential workers. Give back: either get immunized and masked or stay in your house.

Thank you.

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Fuzzy Poet Doctor and the small child

I think I finally understand what I have been doing in clinic all these years. And not just in clinic. As a theory it explains both why patients, nurses, hospital staff and specialists really really like me and my fellow Family Practice doctors, particularly the males, and the administrators, really really do NOT like me.

I am on a plane flying to Michigan a few weeks ago. Double masked. N95 with another mask over it. Sigh.

A friend keeps saying that he can see into me. He can, but he can see thoughts. Not feelings. I am wondering if I see feelings. But I see the stuffed feelings particularly, the ones that people keep hidden. They are like clouds.

And then I think, oh.

I automatically scan any new person for their small child. The inner small child, who is often damaged and hidden. The small child is hidden under those stuffed feelings, which I think of as monsters. In Ride Forth, I am writing about pulling every monster feeling that I can find stuffed out and letting myself feel them. And that people do not like seeing me like that. Their monsters attack me!

Except that the monsters don’t attack. The monsters come to me and say, “Please, please, help me. I want out. The small child needs to heal.” The monsters lie their monstrous heads in my lap and weep.

Now WHY would I develop this skill? That is weird.

I develop it because my parents both drink. The myth in the family is that it was my father. But my mother’s diaries and also her stories make it clear that she drank heavily too. I think they were both alcoholics. And she told two stories about me trying to get someone to get out of bed to give me food as a toddler. As jokes. But it is not a joke. I have food insecurity. At every meal, I think of the next one and whether there is food available. My daughter has it too….. epigenetics.

I think that the only way I could love my parents was to have compassion for them. Once you see another person’s damaged small child, then how can you not feel compassion for them?

With patients I learned to be very very delicate and gentle about asking about the cloud. Just gently. Sometimes people open up on the first visit. Sometimes they shut tight like a clam and I back off. Sometimes they return the next visit or the 3rd or the 8th or after a couple years… and say, “You asked me about this.”

It’s nonverbal communication. The reason why I take the WHOLE history MYSELF at the first visit is for the nonverbal communication. When the person doesn’t want to answer a question, veers away from a topic, switches subjects: there is my cloud. That is where the hurt is. That is where the pain is.

The first cracks in the United States medical system collapse are appearing. Not doctors quitting, not nurses, but medical assistants. Here is an article about how clinics all over can’t hire medical assistants. Because there are tons of jobs, employers are offering more money, why would you do a job where you may well be exposed to covid-19 if you can do something else? And make as much money or more….

The cracks will widen. Ironically doctors are doing what I have done for the last ten years: “rooming” the patients themselves. Ha, ha, good may come out of it, after the disaster. Which is getting worse fast. If people don’t put their masks on and don’t social distance and don’t get vaccinated, I predict more deaths in the US this winter then last winter. Sigh. And in the US we will run out of medical assistants, doctors and nurses.

It is ok to gently ask a patient about that cloud. It is not polite to “see” it in a Family Medicine colleague or and administrator. I can’t “not see” it. I can’t turn it off. However, on the plane my behavior changed even before I could put all of this into words. The words are that I have to be as gentle with everyone as I am with patients.

And the trip felt so odd. I was putting this into effect before I had words. That is how my intuition works. But everyone, absolutely everyone, was kind to me on the trip. A Chicago policeman helped me in the train station and was super kind. It was weird, weird, weird, with bells on. It took me a few more days to be able to put it into words.

Problem intuited, after 60 years of study. Implementation of solution proceeds immediately. Logical brain struggling to catch up, but results satisfactory long before logical brain gets a handle on it.

Pretty weird, eh? I think so. My doctor said that an episode of Big Bang Theory could be written just by following me around for a day. I think it was both saying that I am smart AND that I have no social skills. But I have implemented the social skills program already. She’s just upset that I gave her justifiable hell two visits ago and also…. I do hide my brain. Because sometimes colleagues are jealous.

But maybe they should not be jealous. Maybe they can learn it too. Maybe I can teach. Maybe….

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Top ten causes of death: US 2020

Top ten causes of death US 2020, according to JAMA, here.

Total deaths: 3,358.814
Contrast total deaths in 2019, at 2,854,838. That number had been on a very slow rise since 2015 (2,712,630) to 2019 (2,854,838). That increase over four years is 142,208 people. Then the death rate suddenly jumps 503,976 people in one year. Ouch. I cannot say that I understand vaccine refusal.

1. Coronary artery disease: 690,882
Heart disease still wins. And it went up 4.8%. It is suspected that people were afraid to go to doctors and hospitals. I saw one man early on in the pandemic for “constipation”. He had acute appendicitis. I sent him to the ER and his appendix was removed that day. He thanked me for seeing him in person. Might have missed that one over zoom.

2. Cancer deaths: 598,932
This is cancer deaths, not all of the cancers.

3. Covid-19: 345,342
I have had various people complain that covid-19 is listed as the cause of death when the person has a lot of other problems: heart disease, cancer, heart failure. The death certificate allows for more than one cause but we are supposed to list the final straw first. I cannot list old age, for example. I have to list: renal failure (kidneys stopped working) due to anorexia (stopped eating) due to dementia. That patient was 104 and had had dementia for years. But dementia is not listed as the final cause. So if the person is 92, in a nursing home for dementia and congestive heart failure, gets covid-19 and dies, covid-19 is listed first, and then the others.

4. Unintentional injuries: 192,176
Accidents went up, not down, which is interesting since lots of people were not in their cars. However, remember that the top of the list for unintentional injuries is overdose death, more by legal than illicit drugs. If there is no note, it’s considered unintentional. Well, unless there is a really high blood level of opioids and benzos and alcohol. Then it becomes intentional. They do not always check, especially if the person is elderly. The number rose 11.1%, which seems like a lot of people.

5. Stroke: 159,050
This rose too.

6. Chronic lower respiratory diseases: 151,637
This went down a little. This is mostly COPD and emphysema. So why would it go down? Well, I think bad lung disease people were dying of covid-19, right?

7. Alzheimer’s: 133,182
This seems to belie me putting renal failure due to anorexia due to Alzheimer’s. I think they actually read the forms and would put that as Alzheimer’s rather than renal failure, because it is not chronic renal disease.

8. Diabetes: 101,106
This rose too. 15.4%, again, probably partly because people avoided going to clinic visits. Also perhaps some stress eating. Carbohydrate comfort.

9. Influenza and pneumonia: 53,495
So this went up too in spite of a lot less influenza. Other pneumonias, presumably.

10. Kidney disease: 52,260
This went up.

And what fell out of the top ten, to be replaced by covid-19?

11. Suicide: 44,834
This actually went down a little. What will it do in 2021?

So what will 2021 look like? I don’t know. It depends what the variants of covid-19 do, depends on what sort of influenza year we have, depends on whether we are open or closed, depends if we bloody well help the rest of the world get vaccinated so that there is not a huge continuing wave of variants.

Today the Johns Hopkins covid-19 map says that deaths in the US stand at 608,818 from covid-19. If we subtract the 2020 covid-19 deaths, we stand at 263,495 deaths from covid-19 so far this year. Will we have more deaths in the US from covid-19 than in 2020? It is looking like yes, unless more people get immunized fast.

Take care.

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Oxygen testing

“If oxygen might help with chronic fatigue, as it has helped you,” a friend asks, “how do I get on oxygen?”

Complicated answer.

First of all, one of the things that is not clear, is what recovery looks like. I think I’ve had low grade chronic fatigue for the last 7 years compared to my “normal”. Now, will I get off oxygen? I don’t know. I am hoping for September but it may be that 7 years of low grade hypoxia means I have lung damage and no, I won’t get totally off oxygen.

They have apparently recently made the guidelines for oxygen more stringent. I sort of missed that update, even though I just recertified in Advanced Cardiac Life Support. You now have to have an oxygen saturation that goes to 87% or below. It used to be 88.

Now, you can test this at home with a pulse oximeter. In 2005 after the influenza, I held my saturations but my heart rate would go up to 135. Which means that I walked across the room very very slowly because a heart rate of 135 sustained does not feel good at all. Normal is 70-100 beats per minute. You can measure pulse with just a second hand, number of beats in a minute. For oxygen saturation, you need the pulse ox and it will measure both heart rate and oxygen saturation.

So: measure pulse and saturation at rest first. Write them down.
Then walk. I usually send patients up and down the hall three times then sit them down and watch the pulse ox. In some, the heart rate jumps up. If it’s over 100 and they are getting over pneumonia, I don’t want them back at work until it is staying under 100. Or if sitting they are at a pulse of 60 and then walking it’s 95, well, I think that person needs to convalesce for a while yet. They can test at home.

As the heart rate returns to the baseline, the oxygen level will often start to drop. Does it drop to 87? Describe the test to the doctor and make sure the respiratory technician does it that way and also they should do pulmonary function tests. Mine were not normal.

Now, what if the oxygen doesn’t drop to 87? We are not done yet. What does the person do for work or do they have a toddler? If they have a toddler do the same test carrying the toddler: they sit down, exhausted and grey and this time the oxygen level drops below 87. If they do not have a toddler, do the test with two bags of groceries. Or four bricks.

When I did the formal test, the respiratory therapist said, “Let’s have you put your things down so you don’t have to carry so much.”

“I’d rather not.” I said, “I want to be able to walk on the beach, so I need the two small oxygen tanks, my bird book, camera, binoculars and something to eat.”

“Oh, ok,” she said.

So I did the test with two full tanks of oxygen, small ones, and my bird book and etc. I dropped like a rock loaded. I think I would have dropped not loaded but perhaps not as definitively. Still hurts to carry anything, even one tank of oxygen.

We are making a mistake medically when we test people without having them carry the groceries, the toddler, the oxygen tank. My father’s concentrator is pre 2013. It weighs nearly 30 pounds. Now they make ones that weight 5 pounds. Huge massive difference.

Good luck.

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I don’t think I realized what I had gotten myself into, but it seemed like the potential for fun and insanity were there in equal parts

sometimes you know things
without knowing

sometimes you no things
without noing

sometimes you know things
without noing

sometimes you no things
without knowing

sometimes you koanow things
without knowing

sometimes you no things
without koanowing

sometimes you koanow
without koanowing

sometimes you koanow

snow

also published on another site today.

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still life

From the beach yesterday morning. I say still life, but there could be mites in the feather and the plants are still alive and no doubt there are lots of microscopic plants and animals in this picture. I am wondering how it is really possible to be vegan with bacteria around. Do they not count?

Do corals have venation? The feather does.

For the Ragtag Daily Prompt: venation.

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He just left his body

This is about memory loss.

One of my patients eventually had to have her husband admitted to memory care. He was falling, he was angry, he outweighed her by 50 pounds and he was incontinent. When he fell, she could not get him up.

She went to our hospital Grief Group and came to see me, angry.

“They said he’s still alive!” she snarls. “I got mad and said, no, my husband is gone! He just left his body!”

“I’m so sorry.” I say. “I am sorry that they don’t understand.”

“I’m selling his stuff.” she says. “I don’t have any use for Ham Radio equipment. And HE doesn’t EITHER, now.”

She stomps out. I am sure she cried too.

That is how I think of Alzheimer’s. Neurons burning out from the present to the past. When the person can no longer talk, they are close. Then they are in the womb and stop eating.

Let them go, let them go, god bless them. Where ever they may be. You may search the wide world over but your memory person is free….

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heatwave tricks

I went to high school in Alexandria, Virginia (Remember the Titans) and we had no air conditioning. I had the upstairs bedroom in front of the house. We were on the road that had the bridge over the train tracks, so we got every ambulance, fire truck and police car sirening from one part of town to the other. b

I live on a “busy” street. When the realtor warned me it was “busy”, I thought, well, not like Alexandria. No gun shots in the house a block over, at least not often. I used to hear the helicoptors landing at the hospital four blocks away, but now that I am not on call, my brain dismisses that as a “not worrisome” noise.

So here are my tricks to stay cool.

  1. Get a bandana or headband wet with cold water. Wrap it around your head. Keep wetting it as needed.
  2. If you are going outside, put a hat over the bandana or headband. If it is a straw hat, you can wet it too. Ditto wool.
  3. Stick your feet in cold water.
  4. Fountains make sounds that make you feel cooler. Find a website with a stream or water sounds. Let it play.
  5. Drink lots of water.
  6. Salt. Now, if you have high blood pressure or heart disease or congestive heart failure, be really careful. My symptom of being too low in salt is feeling nauseated and a bit off and woozy. Those are professional doctor terms, ok? I bought 5 kinds of chips yesterday, beer, seltzer (no sugar) and ice.
  7. Do NOT drink sodas to cool off. Most sodas have salt hidden under the sugar. Screw up your hypertension and the congestive heart disease. Oh, and kidney disease and some liver things. Hey, talk to your doctor. They will say “Do not drink sodas. They are the EVIL dwelling on earth.” Well, ok, your doctor might not say the second sentence. I said stuff like that.
  8. Get ice, put it in a cooler, and put in water, maybe beer if you are healthy enough, (go light on the beer. Max seven drinks weekly for women, fourteen for men, and no saving it up for the weekend. The recommendations are different in the UK and different again in Europe. Who is right? Science is a moving target. It is never DONE. Dang ol science. Just give us the stupid finished book so we can stop arguing about it all…. heh. The truth is, we’d argue about something else.) go light on juice (because sugar), cut the juice in half with seltzer or better yet just drink the seltzer. Now, seltzer has salt again, so all those people who has to watch salt intake… oh, shoot, that is everyone. I drank one beer yesterday and one seltzer and a lot of water and in the morning tea.
  9. Consider sleeping outside. It’s cooler here once it cools off! Alexandria, Virginia didn’t cool off. It would be 98% humidity and 98 degrees. So HOW did I sleep in that?
  10. Take a wet washcloth to bed. Wipe down your arms and face. Get your hair wet right before bed if you need to. Put a towel on your pillow. That, plus a fan blowing over me from the open window, and I could sleep, even in 99 degree weather with 98% humidity.
  11. Water animals, plants and don’t forget your trees. I’ve been watering the trees in the early morning and the lichen on the trunks turns BRIGHT GREEN when I do. Happy lichen. I am watering the leaves of everything in the garden in the early morning, to try to help the plants stay cool. Evaporation helps them too.
  12. Take heat stroke seriously. If someone with you stops making sense, then think about an ambulance and do not let them drive. If the core temperature gets too high, people can die, and they are too goofy to drink water. It also can be damn hard to put an iv into someone dehydrated so call early rather than late. Take care!
  13. Curtains. Shut the curtains to the east in the morning. Open them and shut the ones to the south at noon. Open them and shut the ones to the west in the afternoon.

Ok, so I put some rocks in the Beatnik bathtub fountain so that if a mouse falls in, it has somewhere to climb out. Then I went to QFC looking for a sprinkler. I would be hobbling through the sprinkler, but it’s still very cooling. They were out. However, I found fish. Squirt fish. They promptly went in the fountain.