Covid-19: Long Haul

https://www.bbc.com/news/av/world-us-canada-58918869 Some people with Long Haul Covid-19 are having to relearn how to walk and talk.

https://www.bbc.com/news/uk-england-leicestershire-59674203. Patients who were hospitalized are still affected at 5 months and one year after they are released from the hospital. Being female and obese are big risk factors. The article says “Long Covid has the potential to become highly prevalent as a new long-term condition.”

One more:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8146298/ ” While the precise definition of long COVID may be lacking, the most common symptoms reported in many studies are fatigue and dyspnoea that last for months after acute COVID-19. Other persistent symptoms may include cognitive and mental impairments, chest and joint pains, palpitations, myalgia, smell and taste dysfunctions, cough, headache, and gastrointestinal and cardiac issues.”
“One puzzling feature of long COVID is that it affects survivors of COVID-19 at all disease severity. Studies have discovered that long COVID affects even mild-to-moderate cases and younger adults who did not require respiratory support or hospital or intensive care. Patients who were no longer positive for SARS-CoV-2 and discharged from the hospital, as well as outpatients, can also develop long COVID [24,30,31,41,50]. More concerningly, long COVID also targets children, including those who had asymptomatic COVID-19, resulting in symptoms such as dyspnoea, fatigue, myalgia, cognitive impairments, headache, palpitations, and chest pain that last for at least 6 months [51–53].”

And the symptoms? “The most common ongoing symptoms were fatigue, muscle pain, physically slowing down, poor sleep and breathlessness.”

Yes, the same as mine.

My initial evaluation of Long Haul Covid-19 patients will cover three areas:

1. Behavioral Health. Are they having brain fog, feeling slowed, feeling like they can’t think? Is that what happened during the Covid-19 or did the opposite happen? Were they manic/ADHD/OCD etc? What happened in the weeks leading up to getting sick? Any major worries or life trauma? Lose a job, a relationship, someone in the family die? I am looking for a dopamine antibody pattern.

2. Musculoskeletal Chronic Fatigue. What muscles work and which muscles don’t work? If they need to lie in bed for 20 hours a day, both slow and fast twitch muscles are affected. If they are short of breath, they should have pulmonary function tests, including a loaded and unloaded walk test. Are their oxygen saturations dropping? They also need a sleep study. Check for sleep apnea. Any signs of ongoing infection with anything? Teeth, sinuses, ears, throat, lungs, stomach, lower gut, urinary, skin.

3. Musculoskeletal Fibromyalgia. WHEN do their muscles hurt? Is it after eating? Do they fall asleep after they eat or does their blood pressure drop after eating? What diet changes have they made? Are there things they have identified that they can’t eat? Gluten, lactose, meat, sucrose, fructose, nightshades, whatever. I am looking for antibodies to lysogangliosides.

Treatment:

High antibody levels can be lowered somewhat just with “lifestyle changes” aka no drugs.

A. Treat infection if present. Look for strep A with an ASO, since we have an occult one that is in the lungs, not the throat. For fungal infection, even just on the skin, lower blood sugar as much as tolerated. This may mean a ketotic diet.

B. Treat behavioral health with drugs if emergent. If suicidal or really losing it (meaning job/relationships/whatever), then drugs may be needed. But not forever. Avoid benzodiazepines. Check for addictions.

C. Lower antibody levels:
a. Lower stress. Many people will resist this. Counseling highly recommended, ‘cept they are all swamped. Have the person draw the three circles: a day in the present life, their ideal life and then what their body wants. Listen to the body.

b. You can sweat antibodies out: hot baths, hot shower, steam room, sauna, exercise. Daily in the morning, because cortisol rises when we get up, and so levels should be lowered.

c. Is there a stimulant that works for this person to calm them down? Or an antidepressant if they are slowed instead of sped up. The relatives of dopamine that work for ME are coffee caffeine and terbutaline. Ones that do NOT work for me include albuterol and tea caffeine. Ones that I have not tried include theophylline, that new relative of albuterol and ADHD meds like adderall. This will be individual to the person because we all make different antibodies. We are looking for a drug that displaces the dopamine antibodies. For people who are slowed or have brain fog, the stimulants may not work. I would try the SSRI antidepressants first, like sertraline and citalopram, unless the patient tells me they don’t work or make them anxious. I would screen for PTSD. For high PTSD scores and high ACE scores, I would use the old tricyclics, mirtazapine (which is NOT a benzodiazepine), wellbutrin or trazodone. Again, avoid benzodiazepines. Also check how much alcohol and marijuana are on board, because those are definitely going to make brain fog worse. The functional medicine people are treating mystery patients with hyperbaric oxygen chambers and I suspect that this works for the people with blocker tubulin antibodies.

d. Muscle pain/fibromyalgia symptoms. Avoid opioids, they will only work temporarily and may addict. Avoid muscle relaxants, they will only work temporarily. Again, the tricyclics may help. The newer antiseizure drugs that are indicated for fibromyalgia are possibilities, though as an “old” doctor I am conservative about “new” drugs. Gabapentin, pregabalin, and if the person is sped up, antiseizure medicines that are used for mania. GENTLE exercise. The line between me having a good day today and overdoing is knife thin. On the overdoing days I go to bed at 5 pm. I went to sleep at 5 pm yesterday and 6:30 last night. I sang for church last night and even though I’d driven myself there, one of the quartet offered to drive me home. “Do I look that grey?” I asked. “Yes.” he said. I turn grey from fatigue and it can be sudden. Right now it’s after my second meal. If I am active, I will fall asleep after lunch if I can. If I go really light on lunch, I crash right after dinner. And remember, I am one of the lucky people who only have fast twitch muscles affected, not fast and slow twitch.

I am adding this to yesterday’s Ragtag Daily Prompt: hopeful.

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!

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.

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.

Covid-19: caring for yourself

audio version, covid-19: Caring for yourself

A friend took his father to the ER in the next bigger town, sent there for admission to the hospital from the clinic. His father is in his 90s, has heart failure, and his legs were puffed up like balloons with weeping blisters.

They were in the ER for 13 hours, never given food though it was promised, the staff couldn’t even find time to bring a urinal and his father was not admitted. He was sent home. No beds. On divert.

Ok, so when should you go to the hospital right now? Only if you really really can’t breathe….

First, the emergencies. An ER nurse friend talks about “happy hypoxia” where people do not feel bad but have an oxygen saturation of 50%. I suspect that this is when their lungs really are swelling shut very fast. They will turn blue quickly. Call an ambulance. In the 1918-1919 influenza, soldiers “turned blue and fell over dead”. In Ralph Netter’s book on pulmonary diseases, he has a drawing of the lungs of a person who died from influenza pneumonia. The lungs are basically one big red purple bruise with no air spaces. So if a friend is goofy and their lips are turning blue: AMBULANCE.

The one in five hospitals that are 95% full or more in the US are now cancelling all of the elective surgeries: knee replacements, hip replacements, non emergent heart surgeries, all of it.

If you are not dying, do not go to the emergency room if you are in one of the totally swamped areas.

So how to care for yourself with covid-19? Like influenza, it is pretty clear that it either causes lung swelling or the lungs fill with fluid or both. With lung swelling you may be able to stay home. First take your pulse. If you have a pulse oximeter, great, but no worries if you don’t. .What is your resting heart rate? Count the number of heart beats in 60 seconds

If it’s 60-100, that is good. It’s normal. If it is 120 at rest, that is getting worrisome. If you are short of breath at rest and your pulse is over 100, call your doctor. If they can get you oxygen, you still may be able to stay home. If not, emergency room.

Now get up and walk. Do you get short of breath? Sit back down and again, count the number of heartbeats when you are sitting. If your resting pulse was 90 and you jump to 130 walking, you have lung swelling. Functionally you have half the normal air space and so your heart is making up the difference. How to cope? Well, walk slowly. Walk during the day, do get up because otherwise you may get a leg blood clot, but really minimize your activity. Now is not the time to rearrange the furniture. Also, you may not go to work until your walking or loaded pulse is under 100.

If your pulse does not jump up when you walk, next try walking loaded. That is, carry something. Two bags of groceries, a toddler, a pile of books. Go up the stairs. Sit down and take your pulse when you are short of breath or it feels like your heart has speeded up. I am in this category. My pulse is 70, oxygen at 99 sitting. Walking my pulse jumps to 99. Walking loaded my pulse goes to 125 and my oxygen level starts dropping, need oxygen once it gets to 87. I tried a beach walk without oxygen 3 weeks ago. I photographed the pulse ox when it was at 125 with O2 sat at 87. I still need oxygen.

The treatment for lung swelling is rest. This is my fourth time, so I am used to it. Some people will have so much swelling they will need oxygen at rest. If the lungs swell shut, they need to be intubated or they die. Suffocation is not fun. The other treatment is not to catch another virus or a bacteria on top of the present lung swelling. Wear mask, get vaccinated, put out the cigarrette, no vaping, pot is terrible for the lungs too and increases the risk of a heart attack.

With my four pneumonias, the first two made me tachycardic and it took two months for the lung swelling to subside. It sucked. Inhalers don’t work, because they work by bronchodilating. You can’t bronchodilate swollen lung tissue. The steroid inhalers might help a little but they didn’t help me. The third pneumonia took 6 months to get back to work and then I was half time for 6 months. This time I am five months out today and I still need oxygen. Darn. Don’t know if my lungs will fully recover. They may not.

So: rest. Good food. Avoid substance abuse. Mask all visitors and don’t go to parties/raves/concerts/anything. Oxygen if needed and if you can get it.

Take care.

The photograph is me wired up for a sleep study a week ago. The technician took it at my request. I won’t have results until next week.

Covid-19: A gentle answer

I went to have a hair cut today and went in three shops since I was downtown anyhow.

There are lots of tourists and visitors walking around without masks.

In one shop the owner asks if I am Dr. O, and it turns out her daughter babysat for my children 19-20 years ago. We had a nice discussion about our offspring. We are both wearing masks.

In a mineral store somehow the covid-19 subject comes up. I say that I am wearing a mask because I am on oxygen and vulnerable, and even though I am vaccinated, if I get covid-19, it might kill me.

The two owners are not wearing masks. The woman says, “We are both vaccinated, but I am just really confused about what to do.”

I say, “Well, I am a Family Physician. Let’s take chicken pox. If someone is exposed, it can take 21 days for them to break out in the rash. They will be contagious for 1-2 days before they have symptoms. The problem is that it can be ANY of those 21 days. After they break out in the rash, they are contagious until every pox is crusted over. So it can be six weeks that they are possibly or certainly contagious. With Covid-19, the Delta Variant is so infectious and again people may not have symptoms yet, so I am wearing a mask any time I am around strangers.”

The woman says, “Thank you for telling me about it. It’s helpful to hear from a professional.”

“You’re welcome.” I say, gathering my bag to go.

“Look,” she says, “I am putting on my mask now!”

I look and she is.

practicing grandmother

My sister sends me a t-shirt years ago.

It said, “I don’t know if I am the good witch or the bad witch.”

I burst into tears and put it in the trunk of my car. I never wear it. I am the designated bad witch for half my family. We won’t go into that.

She gets a shirt too. Hers is the green one. Mine is black.

She is dead, in 2012, breast cancer. It’s hard to describe the fallout. Toxic and radioactive. But… I have decided not to be a witch.

Instead, I am a practicing grandmother.

Really I’ve been one for a while. There was a young couple who lived down the street with two children. This was in 2014. I was a Facebutt friend, so sometimes noted what was happening. The father has to travel for his job. The mother is trying to care for two kids and work and so on… been there.

In 2014 I am recovering from my third round of pneumonia. This third round it takes six months before I can return to work. Short of breath and coughed if I talked. The state medical watch doctors went to disable me but I fight them tooth and nail. I win.

I wander down to the neighbor and offer my services. She already knows me. She is instantly grateful and two year old T is introduced to me, again. He doesn’t really remember me. She explains that he is coming to my house for a little while and then back home.

T and I walk towards my house.

A nuthatch calls.

I stop and reply. In college I took ornithology and the teaching assistant could do a barn owl call so well that the barn owls would do a territorial fly over at night to see who had the weird accent. Marvelous.

The nuthatch and I went “enh” back and forth. T is amazed. This woman talks to birds. Then we see the nuthatch! I point out how nuthatches come down a tree head first. “If you hear that call, it’s a nuthatch. Look for it.” The nuthatch is very cooperative. Magic.

We get to my house. T is clutching a book. “He’s taking it everywhere,” sighs his mother. “I’m not sure why.”

So first we read the book. It is a board book about a farm. Each page has a central picture and then there are pictures around the edges with the word under each picture. On one page T says, “Haaaaay.”

“Oh!” I say, delighted. “You can read HAY!”

His face lights up. An adult who gets it! Yes! He can read HAY!

On another page he says HAY. “Oh,” I say, “That is straw. Straw is a lot like hay but it’s not exactly the same.”

He is very serious absorbing that information.

I show him my closet. There is a stick horse. Only it isn’t a horse: it’s a unicorn dragon, with a forehead horn and wings. When you press a button it’s eyes flash and it roars.

Ok, that’s pretty scary. He wants the closet door closed and he does NOT want to play with the dragon.

Next is pouring. I get out a towel and put it on the kitchen floor. I get out a rather nice expresso set. Bright colors. Orange and green and yellow and blue. I fill the coffee pot with water and invite him to sit on the towel. “You can pour the tea.”

He looks at me with surprise. He picks up the coffee pot. He looks at me again. “Go ahead. It’s ok.” He starts pouring into a cup. He pours until the cup overflows and the saucer overflows and he keeps pouring. The coffee pot is empty. He looks at me a little warily. This is technically spilling and he knows it.

“Would you like more in the teapot?”

He nods.

I refill the coffee pot with water and he starts again, with a different cup.

When I return him to mom, after two hours, he’s damp. “Sorry, he got a little wet, but it’s just water,” I say cheerfully. Mom is too harried to do much more than look resigned at a change of clothes.

Next time he comes with a change of clothes and his large stroller, in case he goes down for a nap.

And first off, he goes to the closet. Time to hear that dragon roar again.

even if

even if

I never see you again
you never speak to me again
you never love your bearish parts
you never let yourself get angry
you never let yourself get sad
you never let yourself feel
you tell yourself you are happy
you tell yourself everything is the way it should be

even if

I never see you again

I still love you
I still forgive you

I still love you

I hope that you truly do

find happiness