Category Archives: survival

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Lung swelling and long covid

I wrote this in 2017, about influenza. However, I think covid-19 can do the same thing. Part of long covid is letting the lungs really heal, which means infuriating amounts of rest and learning to watch your own pulse. Watching the pulse is easier then messing around with a pulse oximeter. The very basics of pulse is that normal beats per minute is 60 to 100. If your pulse is 70 in bed and 120 after you do the dishes, you need to go back to bed or the couch and REST.

From 2017: Influenza is different from a cold virus and different from bacterial pneumonia, because it can cause lung tissue swelling.

Think of the lungs as having a certain amount of air space. Now, think of the walls between the air spaces getting swollen and inflamed: the air space can be cut in half. What is the result?

When the air space is cut down, in half or more, the heart has to work harder. The person may be ok when they are sitting at rest, but when they get up to walk, they cannot take a deeper breath. Their heart rate will rise to make up the difference, to try to get enough oxygen from the decreased lung space to give to the active muscles.

For example, I saw a person last week who had been sick for 5 days. No fever. Her heart rate at rest was 111. Normal is 60 to 100. Her oxygen level was fine at rest. Her oxygen level would start dropping as soon as she stood up. She had also dropped 9 pounds since I had seen her last and she couldn’t afford that. I sent her to the emergency room and she was admitted, with influenza A.

I have seen more people since and taken two off work. Why? Their heart rate, the number of beats in one minute, was under 100 and their oxygen level was fine. But when I had them walk up and down a short hall three times, their heart rates jumped: to 110, 120. Tachycardia. I put them off from work, to return in a week. If they rest, the lung swelling will have a chance to go down. If they return to work and activity, it’s like running a marathon all day, heart rate of 120. The lungs won’t heal and they are liable to get a bacterial infection or another viral infection and be hospitalized or die.

I had influenza in the early 2000s. My resting heart rate went from the 60s to 100. When I returned to clinic after a week, I felt like I was dying. I put the pulse ox on my finger. My heart rate standing was 130! I had seen my physician in the hospital that morning and he’d gotten a prescription pad and wrote: GO TO BED! He said I was too sick to work and he was right. I went home. It took two months for the swelling to go down and I worried for a while that it never would. I dropped 10 pounds the first week I was sick and it stayed down for six months.

Since the problem in influenza is tissue swelling, albuterol doesn’t work. Albuterol relaxes bronchospasm, lung muscle tightness. Cough medicine doesn’t work very well either: there is not fluid to cough up. The lungs are like road rash, bruised, swollen, air spaces smaller. Steroids and prednisone don’t work. Antiviral flu medicine helps if you get it within the first 72 hours!

You can check your pulse at home. Count the number of beats in one minute. That is your heart rate. Then get up and walk until you are a little short of breath (or a lot) or your heart is going fast. Then count the rate again. If your heart rate is jumping 20-30 beats faster per minute or if it’s over 100, you need to rest until it is better. Hopefully it will only be a week, and not two months like me!


Feel free to take this to your doctor. I was not taught this: I learned it on the job.

I took the photograph, a stealthie, in June 2021, when I was still on oxygen continuously.

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Covid-19: in flew Enza

Survey shows 6 in 10 Americans will delay or skip flu shots this year.

Oh, dear. Not going to get your influenza shot? I am. Well, you say, YOU are on oxygen and have tricky lungs and keep yammering about imaginary Pandas.

Yes, and you should get your vaccine anyhow, even if you are healthy as a hoss.

If not for yourself, for everyone else. Because usually influenza kills 12,000 to 61,000 US citizens a year and gosh, guess what it will do to post-Covid long haulers. Um, kill, I would expect. And with a very low influenza winter last winter, because covid and masks and social distancing, immunity is down and the infectious disease folks are anticipating that it could be a worse than usual influenza year. How many people have long covid? This just in: More than half of covid survivors experience post acute sequelae to covid 19 (PASC) at 6 months after. ““The most common PASC involved functional mobility impairments, pulmonary abnormalities, and mental health disorders,” wrote Destin Groff, Penn State College of Medicine and Milton S Hershey Medical Center, Hershey, Pennsylvania, and colleagues. ”These long-term PASC effects occur on a scale that could overwhelm existing health care capacity, particularly in low- and middle-income countries.”

AND not only that, even if you or your friend or mother or grandmother don’t die of influenza, far more people clog up emergency rooms and doctor’s offices. The “CDC estimates that influenza has resulted in between 9 million – 45 million illnesses, between 140,000 – 810,000 hospitalizations and between 12,000 – 61,000 deaths annually since 2010.”* And the doctors and nurses and emergency people and nursing home employees and first responders are already short staffed and tired. So if you won’t get your flu vaccine for the general public, get it for the first responders.

AND before you tell me that “the vaccine gave me flu”, hello, it takes up to two weeks for the flu vaccine to confer immunity, and so if you got influenza two days later, you didn’t get it from the vaccine, you got it because you got the vaccine too late. Vaccine complications, well, I have seen one complication in my 30 years of Family Medicine, and it was someone I knew, not a patient. And half the people who tell me that “the vaccine gave me flu”, stomach flu with diarrhea and barfing is not influenza. It’s more likely to be a hangover than anything else. I see a lot more post alcohol “stomach flus” than true food poisoning. Quit drinking so much alcohol, ok?

And while you are at it, you’d better get the Covid-19 vaccine while it is still available free. And before you get on an airplane for Thanksgiving or go Trick or Treating with all those little germ spreaders or fly off to see family at Christmas/Kwanza/Winter break/whatever. Two weeks before, at least. Like, NOW. Or don’t, whatever, just don’t whine to ME about more deaths.

This public service message has been brought to you by a beneficent alien lizard. Feel free to send money.

*https://www.cdc.gov/flu/about/burden/index.html

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Adverse Childhood Experiences 12: welcome to the dark

Welcome to the dark, everyone.

When you think about it, all the children in the world are adding at least one Adverse Childhood Experience score and possibly more, because of Covid-19. Some will add more than one: domestic violence is up with stress, addiction is up, behavioral health problems are up, some parents get sick and die, and then some children are starving.

From the CDC Ace website:

“Overview:Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur in childhood. ACEs can include violence, abuse, and growing up in a family with mental health or substance use problems. Toxic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. However, ACEs can be prevented.”

Well, can they be prevented? Could Covid-19 be prevented? I question that one.

I have a slightly different viewpoint. I have an ACE Score of 5 and am not dead and don’t have heart disease. I spent quite a bit of time thinking about ACE scores and that it’s framed as kids’ brains are damaged.

I would argue that this is survival wiring. When I have a patient where I suspect a high ACE score, I bring it up, show them the CDC web site and say that I think of it as “crisis wiring” not “damaged”. I say, “You survived your childhood. Good job! The low ACE score people do not understand us and I may be able to help you let go of some of the automatic survival reactions and fit in with the people who had a nice childhood more easily.”

It doesn’t seem useful to me to say “We have to prevent ACE scores.” Um. Tsunamis, hurricanes, Covid-19, wars… it seems to me that the ACE score wiring is adaptive. If your country is at war and you are a kid and your family sets out to sea to escape, well, you need to survive. If that means you are guarded, untrusting, suspicious and wary of everyone, yeah, ok. You need to survive. One of my high ACE Score veterans said that the military loved him because he could go from zero to 60 in one minute. Yeah, me too. I’ve worked on my temper since I was a child. Now it appears that my initial ACE insult was my mother having tuberculosis, so in the womb. Attacked by antibodies, while the tuberculosis bacillus cannot cross the placenta, luckily for me. And luckily for me she coughed blood at 8 months pregnant and then thought she had lung cancer and was going to die at age 22. Hmmm, think of what those hormones did to my wiring.

So if we can’t prevent all ACE Scores, what do we do? We change the focus. We need to understand crisis wiring, support it and help people to let go of the hair trigger that got them through whatever horrid things they grew up with. 16% of Americans have a score of 4 or more BEFORE Covid-19. We now have a 20 or 25 year cohort that will have higher scores. Let’s not label them doomed or damaged. Let’s talk about it and help people to understand.

I read a definition of misery memoirs today. I don’t scorn them. I don’t like the fake ones. I don’t read them, though I did read Angela’s Ashes. What I thought was amazing about Angela’s Ashes is that for me he captures the child attitude of accepting what is happening: when his sibling is dying and they see a dog get killed and he associates the two. And when he writes about moving and how their father would not carry anything, because it was shameful for a man to do that. He takes it all for granted when he is little because that is what he knows. One book that I know of that makes a really difficult childhood quite amazing is Precious Bane, by Mary Webb. Here is a visible disability that marks her negatively and yet she thrives.

A friend met at a conference is working with traumatic brain injury folks. They were starting a study to measure ACE scores and watch them heal, because they were noticing the high ACE score people seem to recover faster. I can see that: I would just say, another miserable thing and how am I going to work through it. Meanwhile a friend tells me on the phone that it’s “not fair” that her son’s senior year of college is spoiled by Covid-19. I think to myself, uh, yes but he’s not in a war zone nor starving nor hit by a tsunami and everyone is affected by this and he’s been vaccinated. I think he is very lucky. What percentage of the world has gotten vaccinated? He isn’t on a ventilator. Right now, that falls under doing well and also lucky in my book. And maybe that is what the high ACE score people have to teach the low ACE score people: really, things could be a lot worse. No, I don’t trust easily and I am no longer feeling sorry about it. I have had a successful career in spite of my ACE score, I ran a clinic in the way that felt ethical to me, I have friends who stick with me even through PANDAS and my children are doing well. And I am not addicted to anything except I’d get a caffeine headache for a day if I had none.

For the people with the good childhood, the traumatic brain injury could be their first terrible experience. They go through the stages of grief. The high ACE score people do too, but we’ve done it before, we are familiar with it, it’s old territory, yeah ok jungle again, get the machete out and move on. As the world gets through Covid-19, with me still thinking that this winter looks pretty dark, maybe we can all learn about ACE scores and support each other and try to be kind, even to the scary looking veteran.

Take care.

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grounded

This is a poem that I wrote in 2015 or before. It was previously posted here and on everything2.com. I just read a blog where two hockey dads are dead of covid-19. The author is writing about grief. I wrote this when I was struggling with grief and how to really let it in.

grounded

grief is an ox
that stands in the room with me
and overshadows
everything

no
grief
is a plow
pulled by an ox
I try to guide it
in the furrows

no
grief is the heavy ground
the plow turns it
the ox pulls
I guide it
in the furrows

no
I am grieving
I let it be close
I don’t push it
in to an ox
in to a plow
in to the earth
I let it in
I grieve

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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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outfits inappropriate for work 3

Ok, maybe it is not inappropriate for work. But it would be a little weird for work… I was going in the woods with my oxygen tank. “Local doctor of 21 years found eaten by cougar, which then died because it couldn’t digest the oxygen tank.” Heh.

Listening to this, fabulous!!!

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outfits inappropriate for work 2

When pneumonia nearly takes me out, I want COLOR. I think I managed it with this. The skirt is not only silly, but a little short for me to wear to work….

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outfits inappropriate for work

Ok, I have been going through my clothes. I found both the pink bra and the wings in the bottom of a closet. So, I put them on. I did not actually step outside the house wearing this. I think I need a costume party. Anyhow, it’s rather fun trying these silly things on. I’d have to wear the wings over my White Coat to doctor in this outfit…..

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Liars and the lying lies they tell

This blog post: hanging from a telephone wire intrigues me.

Why do the liars lie?

I disagree with Ms. Kennedy.

The liars lie for the same reason that addicts lie. They are not lying to you or to me. They are lying to themselves FIRST. They want to believe what they say.

“My marriage is perfect.”

“I love all my children the same.”

“I never make an error.”

“I talk to my mother every Sunday morning because we are so close and love each other so much.”

“I can see right in to your head.”

“I don’t care about anything.”

“I am happy all the time.”

Whew. A totally easy list to come up with and I could go on and on and on…. and so could you. When someone says something like this… I am always (fill in blank) or I never (fill in blank)… stop. Think. They want to believe it. They might like you to believe it too. They might even kind of know that it’s a lie and very convincing one but the best liars have convinced themselves.

I saw it in clinic all the time. Over and over and over.

It’s the glitter that gives it away. When they come in all glittery and sparkly and their eyes shine and they are too beautiful for words and they charm your socks right off…. check your wallet. They are an addict or a manipulator or they WANT SOMETHING FROM YOU. And there are people who just do it automatically. They lie all the time.

Whatever. When someone reminds me of my mother or my sister… or the other extremely well trained enablers on the maternal side of my stupid family…. ooooooo. The person has my full focused attention. Which thing is the lie? What do they want? What are they going to try to get out of me?

When I trained in buprenorphine treatment, the guy (enabler) that I was dating was horrified. “You can’t treat addicts!” he said.

“Why not?” I asked.

“They LIE.”

I laughed. “ALL patients lie. There are studies. They lie about whether they are taking their blood pressure medicine. They lie about how much salt they are eating. They lie about exercising. The first question I ask if someone’s blood pressure is too high, is “Are you taking the medicine?” More than half the time I get a sheepish, “Yeah, well, no, I ran out of it two weeks ago.” “Yeah, well, then I can’t tell if it’s working or not, can I? And you’ll have to redo the stupid labs once you have taken it for two weeks and come back for another check.” “Ok, ok, I get it.” If you lie to your doctor, well, you might get hurt. Tell them about the pills your friend gave you, tell them about the supplements, and that infected toe? Might help if you tell the truth about it. Even though it was when you um inserted well we were just, like he has an infected um. That is important information and changes which antibiotics I use plus now I want to check for chlamydia and gonorrhea and same sex male so we gotter talk about HIV prophylaxis and this is a 15 minute clinic visit? I am now running late and annoyed. You need another visit in 1-2 days or else I gonna hospitalize yo dumb self.

And WHY do people, and especially people in addiction, lie to themselves?

Damage. ACE scores. Adverse Childhood Experience Scores. They wish that they were that close to their mother. They long for a perfect marriage. They were beaten in secret by the perfect father. The famous man, their grandfather, sexually abused them. The list is endless.

And how do we help? The person I just stopped dating told me that his children said to him “My picker’s broke.” Our pickers are not really broken. We are attracted to the people who can teach us.

In the book Passionate Marriage, the author writes about how we are attracted to the people who have what we lack. What we want to learn. What we are afraid of. What we need to learn. I needed to learn how to really look at anyone I date with my full on intuition right away and also that it is seriously Not Nice of me to get curious, activate my inner scientist and stick around. I recognize the projection on me at some point and then the scientist in me is intrigued. Really? The most recent one said that inside me there is a sweet innocent joyous tiny girl.

Well, I thought. No, not really. There certainly is a baby. But it’s a baby honey badger or a baby Iron Bitch Alien Lizard. Don’t care what you call it. But it is about as sweet as a pissed off porcupine or skunk. Polecat. Octopoggles done got us! Squirting ink and sliding into an impossibly small space and escaping from the acquarium over and over until the captors let me go…..

And that was actually the moment I should have spoken up. Calmly. Kindly. “Um, no. I was never a sweet innocent joyous tiny girl. I was bathed in antibodies to tuberculosis in the womb and no doubt alcohol and my parents were newly married and I came out saying, “What is happening now? Some new torture? Augh! Bright lights! Is there food? I am really really hungry. Feed me or I will eat YOU.” And then I lost my mother for nine months so that I would not catch tuberculosis from her and die. I didn’t really understand it. I thought people kept giving me away and that you couldn’t trust those evil adults.

In the end this is all actually necessary, says the Passionate Marriage author. WHAT? WHAT? Well, in a truly loving relationship, both people will withdraw the projection. The projection is the “falling in love” where the person is golden, perfect, your true love. No, they aren’t. But you love that aspect of them that you want/need/can’t do. True love is when you withdraw the projection and you see the real person and you love them.

It isn’t easy. But people do it. Birds do it, squirrels do it, trees do it, even elementary bees do it… let’s do it… let’s fall in love.

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Free fall

I feel safest with the fallen

Everyone falls
No one is good

I am afraid
Of the people who
pretend to be good

the fallen
don’t pretend

We fell down down down
like an eternity
like it would never end

We were bad
depressed drunk addicted
liars cowards thieves

We held our arms out
There was nothing to stop us
Free fall

All we could do
was pray

We prayed
As best we could
With all our hearts
If we had no words

Falling angels
Caught us

Helped us
Claw our way back

Some people fall
Are still falling
Fall forever

Are they crazy
Or do they choose
To stay with the angels?

The people who say
They are good

We look at them

We know they haven’t fallen

They are lying to us
They are lying to themselves
They are lying to the Beloved
They want to be good
They want what they say to be true

But it isn’t

I meet the eyes of another fallen
Knowledge

I can see the memory
Of infinite free fall
In their eyes.