Category Archives: your health care dollar

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Work place

Mostly I post photographs from outdoors, but this is clinic Friday afternoon. Mordecai took off her feather boa, wig and headdress and came into the exam room to add to a visual discussion about the sacroiliac joints. Mordecai is a plastic skeleton and her sacroiliac joints are attached incorrectly but conveniently for the sellers. After all, her bones don’t have the weight of a real skeleton nor does she have tendons or muscles or skin to connect everything. She is sitting beside my Netter Atlas of Human Anatomy, which I use in clinic every day. To show the knee ligaments and menisci, to show the back muscles, to show the connections of the psoas muscle….

Many thanks to Dr. Netter’s brilliant paintings and also to Mordecai for their help!

 

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Wellness

What is wellness and what is illness?

Many of the people that I see in clinic want healing. But healing is complicated. Many people define healing as “I want to be the way I was six years ago when I felt good.”

I delve into the time when they felt good. Sometimes when I start asking about it, they were very busy. Often very stressed. Often not paying attention to their own care, caring for someone else, a parent, a child, a partner. Or overworking with great intensity. “But I could do it!” they say, “I didn’t feel bad!”

…Maybe not. But the self care was deferred. The body struggled on as best it could, absorbing trauma after trauma, being ignored until a tipping point was reached. Then the switch was thrown and the system crashed…

When my sister died of cancer at 49, the family fought. Lawsuits. I promptly crashed and was out sick for two months. I nearly died too, of sepsis. I thought, I’m not going to be that stupid again. Well, except I was. My father died fourteen months after my sister and I was executor, dealing with a 1979 will. I was sure that I would be sued. I did not cut back work and I didn’t rest. I worked on the estate and cried, evenings and weekends.

After a year, I crashed again. Sepsis, again. I did not die, but this time I was out for ten months and then had to work half time for ten months. And I thought, oh, am I stupid or what? I didn’t take time off when my father died. I just pulled my boots up and kept working, two jobs. Executor and physician.

I made the rounds of specialists. I coughed for six months. Pulmonary. My lungs were slowly improving, very slowly. My muscles were lagging: neurology said they would get better. “When?” I said. “We don’t know,” said the neurologist, grinning. “I hate doctors,” I said. He laughed. On to Ear, nose and throat, then Asthma/Allergy, then Infectious Disease. “We don’t know how to keep you from getting it again.” says the Infectious Disease specialist cheerfully. “No idea.”

Back to work. Half time for ten months. And now my new “full time”. My goal is not to work more than forty hours a week. I spend 4.5-5 hours seeing patients and 3 hours reading and making decisions about labs, specialist notes, ER notes, inpatient notes, pharmacy notes, garbage from insurance companies, medicare’s new and improved impossible rules, continuing medical education, pathology reports, notes from patients and phone calls. And then I go home.

I would have qualified for a diagnosis of chronic fatigue six months into the illness. I didn’t seek it because I didn’t care. I was quite certain that I would get better, though I didn’t know how long it would take. I was quite certain that I would have to behave differently or I would crash again. If I get it again, I don’t think I will be able to do medicine and I like doing medicine. Also, if I get it again, there is a 28-50% mortality rate. Not good odds. So I need to pay attention, rest when the stress reaches the level of stupid, and take care of myself.

It is now thirty months since I got sick. I do actually feel like my muscles are back to normal. My lungs aren’t quite. I can tell when I play the flute that there is some scarring, after three bad pneumonias. But I can play and sing and I am slowly getting back to shape.

But note: I am NOT going back to where I was. I am paying attention. I am changing my job and my life so that I stay healthier. I am not returning to unhealthy levels of work and stress. And if stress in my personal life flips to high, I take time off from work. I have to, to stay healthy.

When I meet a new patient, the ones that are hardest to help are the ones who want to turn back the clock. They want the exact same life back that crashed them. The life that they got sick in. Think of a veteran getting blown up: we don’t expect them to be the same. Think of my 90 year old patient who went through both brain and heart surgery. He was better. He was able to hunt again which was his goal. But he said, “You have not made me feel that I am 20 again.” I laughed and said “And I am not going to. Talk to your higher power.” He was teasing me, but he was also acknowledging that his body and his endurance and his health at 90 was different than at age 20.

We need a new paradigm of wellness. Wellness is not staying the same for one’s entire life. You will not be 20 for 70 years. Wellness is changing as your life changes and paying attention to what you and others need. Wellness is accepting illness and deciding how our life needs to be changed to be well.

I took the photograph of Mount St Helen’s five years ago. The mountain changed too, as we all do.

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My clinic and the state of medicine

January has been the busiest month in clinic since I returned to work in April of 2015 after the ten month systemic strep A hiatus. It took another ten months for my fast twitch muscles to start working again. I was working “half time” for the first ten months after I returned.

Right now, though, my receptionist and I are about maxed out. We saw 4-8 people a day in January, averaging 6.5, and with Martin Luther King’s birthday off. I see patients five days a week, try to stop by 2 pm and then do paperwork until 4 or 5. Lately I have been going in at 7 am, because I am feeling behind. Three very sick patients, one who has been sick and hospitalized nearly weekly since October, are each taking 1-2 hours a week and I can’t get to the routine paperwork. Labs, referral letters that need to go out, reading referral letters that come back and updating the med list, xrays, pathology reports….

Yes, we could hire someone to scan it all faster, but scanning it does not mean it has been read. And it is me that has to read it. One of the complex patients has five specialists and four different electronic medical records are involved. I had to call the rheumatologist, because the doc was not responding to the patient’s calls. I had sent the rheumatologist letters and updates: turned out the doc didn’t read any of them until the patient missed a visit because their car broke down. And another of the specialists said they “didn’t have the notes” from the other hospital. I wrote a letter to ALL of the specialists and said, the notes are in there because I faxed them to our hospital myself. Unfortunately scanned notes are difficult to find in the EPIC electronic medical record. Ironically both hospitals use EPIC but the two versions do not share their information. This is REALLY REALLY BAD. It is bad for patient care and bad for this specific patient. Not only that, but when one of the specialists orders something, the report doesn’t get sent to me as well as them. I tracked down labs and I tracked down an xray report and sent him back to the hospital at that visit. I do not know if the hospitalization could have been averted, but….I’ve told the patient and spouse that if ANYONE orders a test, call me. So I can track down the results.

So it looks like five clinic days a week, seeing up to eight patients a day, will take forty hours or more. This is a rural family practice clinic. I cannot see any way to see more and actually keep up with the information coming in with my patient population, half of whom are over 65. And an additional one is in hospice and another on palliative care.

A fellow doc has retired from medicine, in her 50s. She is “med-peds”: internal medicine-pediatrics, which is sort of like family practice except they don’t do obstetrics, less gynecology and less orthopedics. I hear that she is retiring because every 20 minute clinic visit generates an hour of paperwork. The hospital considers 4 days a week, 18 patients a day, full time. Ok, that is 72 patients a week, seen in four 8 hour shifts. 32 hours plus 72 hours of paperwork. One hundred and four hours. Can’t be done.

I dropped to 3.5 days in 2009 when the hospital said we had to see 18 a day. So 28 hours, 63 patients. 28 hours plus 63 hours. That is 91 hours a week. I still could not keep up with the information coming back from specialists, labs, xrays, pathology reports, medicine refill requests, requests for those evil ride on carts, spurious nonsense from insurance companies, and families calling about their loved ones. All ten fingers in holes in the dyke and 90 other holes spouting water.

Something has to give and something IS giving. Care is falling through the cracks and providers are quitting. I am not quitting, I just am not making anything anywhere near to the “average family practice salary” in the US. And we hear that burnout is now at 54% of primary care doctors. Hello, US. If we don’t go to single payer, you might have to ask your naturopath to take out your appendix. And good luck with that.

If I see 7 per day, five days a week: that is 35 patients. I do longer visits and more paperwork in the room, so call it 45 minutes of paperwork per patient. I see patients from 8:30 to 12 and 1 to 2. 4.5 hours five days = 22.5 hours plus (35 patients x 45 minutes)= 26 hours and now I am at 48.5 hours a week. And then if I have three really sick ones: more.

If we hire help, they have to be paid. Then I need to see more patients in order to generate that pay. Then there is more paperwork that I can’t keep up with. An infinite loop.

Let’s look at my clinic population verses county and state.
Clinic: 2.4% under age 18
20.7% age 19-50
28% age 50 to 64
48.9% over 65
Jefferson county (2014): 16.7% under age 19
51.5 age 19-65
31.8% over age 65
Washington state (2014): 29% under age 19
56.9% age 19-65
14.1% over age 65

We have an older county and nearly half my patients are over 65, and 77.9% of my clinic patients are over age 50.

And I should be reading all the new guidelines as they come out. The newest hypertension guidelines say that the blood pressure should be taken standing in all patients over age 60. Those guidelines are now a couple of years old. My patients tell me that I am the ONLY doctor that they have taking their blood pressure standing. The cardiologists aren’t doing it either. Just this week there are articles in the AAFP journal explaining the blood pressure guidelines. But the doctors need time to READ the articles. The guidelines themselves tend to be 400 pages of recommendations and explanations and a list of hundreds of studies reviewed since the last guidelines. And ok, there are also hundreds of guidelines. On blood pressure, who should be on aspirin, what to do for heart pump failure, urinary incontinence, osteoporosis, toenail fungus.

https://www.uspreventiveservicestaskforce.org/
guidelines: https://www.uspreventiveservicestaskforce.org/BrowseRec/Index
Ok, that is a list of 96 guidelines, which doesn’t even include the hypertension ones. The hypertension guidelines are called JNC 8, for the eighth version:
http://jamanetwork.com/journals/jama/fullarticle/1791497
Here is the two page hypertension JNC 8 algorithm: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf. Memorize it and the other guidelines, ok?
And here is the Guideline Clearing House: https://www.guideline.gov/

This week another clinic suddenly closed and we have gotten walk in patients and calls. About eight so far. We are booked for new patients out to April…..

I took this photograph from the beach as the sun set, camera zoomed. Different mountains were lit up while others were in shadow as the sun went down. This is Mount Baker and friends….

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Vital signs II

Pain is not a vital sign anymore, as I described in yesterday’s post. I wrote this poem in 2006, about painΒ  being the fifth vital sign. I disagreed.

Vital signs II

Pain
Is now a vital sign
On a scale of 1:10
What is your pain?
The nurses document
Every shift

Why isn’t joy
a vital sign?

In the hospital
we do see joy

and pain

I want feeling cared for
to be a vital sign

My initial thought
is that it isn’t
because we can’t treat it

But that isn’t true

I have been brainwashed

We can’t treat it
with drugs

We measure pain
and are told to treat it
helpful pamphlets
sponsored by the pharmaceutical companies
have articles
from experts

Pain is under treated
by primary care
in the hospital
and there are all
these helpful medicines

I find
in my practice
that much of the pain
I see
cannot be treated
with narcotics
and responds better
to my ear

To have someone
really listen
and be curious
and be present
when the person
speaks

If feeling cared for
were a vital sign
imagine

Some people
I think
have almost never felt cared for
in their lives

They might say
I feel cared for 2 on a scale of 10

And what could the nurses do?

No pills to fix the problem

But perhaps
if that question
were followed by another

Is there anything we can do
to make you feel more cared for?

I wonder
if asking the question
is all we need

first draft 5/20/06

I took the photograph Friday afternoon from the beach: two fronts were meeting. What is that like in the sky? Do they fight or welcome each other?

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Pain as a vital sign

A recent article in the Family Practice News says that a survey of 225 physicians reveals that 33% of them think that the opioid crisis in the US is caused by over prescribing opioids. 24% said aggressive patient drug seeking and 18% said it is due to drug dealers. How quickly things change.

In 1996 pain was declared the fifth vital sign, after temperature,Β  pulse (heart rate), respiration rate and blood pressure. I disagreed with it because it focused on pain, by telling the nurses in the hospital and the outpatient providers to always to ask about pain. I thought it would be better to focus on level of comfort than pain. I thought we were using opioids far too freely and I thought that patients were getting addicted. The pain specialists said that we had to treat pain, and we were given very few tools other than opioids. Primary care providers were told that they could be sued for too much or too little pain medicine.

I also disagreed with it because pain is NOT a vital sign. That is, the level of pain does not correlate with illness. If a person has a high fever of 104 I am sure they are sick, a fast or very slow heart rate, a blood pressure too high or two low, they are breathing too fast: these are vital signs. They often correlate to illness and help us decide if this is outpatient, urgent or emergent. But pain does not. A chronic pain patient may have a pain level of 8/10 and yet not be an emergency or in a life-threatening state at all. That does not mean that they are lying or that we don’t wish to help with pain.

In June, 2016, the American Medical Association recommended dropping pain as a vital sign. https://www.painnewsnetwork.org/stories/2016/6/16/ama-drops-pain-as-vital-sign. The Joint Commission for Hospital Accreditation dropped pain as a vital sign in August, 2016. https://www.jointcommission.org/joint_commission_statement_on_pain_management/

Why? Not only were people getting addicted to opiates, but they were and are dying of unintentional overdoses: sedation from opiates with alcohol, with anxiety medicines such as benzodiazepines, with soma, with sleep medicines such as ambien and zolpidem. If the person is sedated enough, they stop breathing and die. The CDC declared an epidemic of unintentional overdoses in 2012: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm and said that more US citizens were dying of prescription medicines taken as instructed then from motor vehicle accidents and guns and illegal drugs.

So the poem below and a second poem I will post tomorrow reflect how I thought about pain as a vital sign. It is not a vital sign, because a high pain level does not tell me if the person is critically ill and may die. It does not correlate. Pain matters and we want to treat it, but the first responsibility is “do not harm”. Letting people get addicted and killing some is harm.

Also, opioids have limited effectivenessΒ and high risk for chronic pain. I have worked withΒ  The University of Washington Pain and Addiction Clinic since 2010 via telemedicine. They say that average improvement of chronic pain with opioids is about 30%. Higher and higher doses do not help and increase the risk of overdose and death. And the risk of addiction.

I think of pain as information. Studies of fibromyalgia patients with functional MRI of the brain show that they are not lying about their pain. In a study normal and fibromyalgia patients were given the same pain stimulus on the hand. The normal patients said that they felt 3-4/10 pain. The fibromyalgia patients felt 7-8/10 pain with the same stimulus and the pain centers lit up correspondingly more in their brains. So they are not lying.

Why would opioids only lower chronic pain about 30% even with higher doses? The brain considers pain important information. We need to snatch our finger away from a flame, stop if we smash our toe, deal with a broken bone. I think of opioids like noise cancelling headphones. Say you are listening to music. You put on headphones/take round the clock opioids. Your brain automatically turns up the gain: the music volume or the pain sensors. Now it hurts again. You take more. The brain turns up the gain. Now: take the noise cancelling headphones off. The music/pain is too loud and it hurts! With music we can turn it down, but the brain cannot adjust the gain for pain quickly.

We do not understand the shift from acute pain to chronic pain, yet. The shift is in the brain. I think that we are too quick to mask and block pain rather than use the information. Now the recommendations for opioids are to only use them for 3-5 days for acute pain and injury. For years I have said with any opioid prescription: try not to take them around the clock and try to decrease the use as soon as possible. Some people get addicted. Be careful.

If we don’t hand people a pill for pain, what can we do? There are more and more therapies. Jon Kabot Zinn’s 30 years of studying mindfulness meditation is very important. His chronic pain classes reduce pain by an average of 50%: better than opiates. Pain and stress hormones drop by 50% in a study of a one hour massage. Massage, physical therapy, chiropracty and acupuncture: different people respond to different modalities. Above all, reassuring people that the level of pain in chronic pain does not correlate to the level of illness or ongoing damage. And pain is composed of at least three parts: the sharp nocioceptive pain, nerve pain (neuropathic) and emotional pain. We must address the emotional part too. We have no tool at this time to sort the pain into the three categories. My rule is that I always address all three. That does not mean every person needs a counselor or psychiatrist. It means that we must have time to discuss stress and discuss life events and check in about coping.

In the survey of 225 providers, 50% estimated that they prescribe opioids to fewer than 10% of their patients. 38% said less than half. 12% estimated that they prescribe opioids to more than half their patients. The survey included US primary care, emergency department and pain management physicians.

Handing people a pill is quicker. But we can do better and primary care must have the time to really help people with pain.

Vital Signs I

In the hospital now
I am told we have a new
Vital sign
Like blood pressure and pulse
We are to measure
Pain
And always treat it

Sometimes I wonder

Mr. X is in the ICU
I tell his family
He may die

On a scale of one to ten
What is his wife’s pain?
His daughter’s
We are not treating them
Only Mr. X

We try to suppress pain
Signals from our nerves
Physical pain is easier

I think of our great forests
We suppressed fire

And that was wrong
If fire is suppressed
Undergrowth builds up
Fuel levels rise
Fire comes
Rages out of control
All is destroyed

If fires burn
More naturally
More regularly
What is left?

At first it looks desolate
The tall trees are burnt
Around their bases
But they live
Adapted to the fire
Majestic pines
Revealed
Would our values were as clear

Some pines
Seeds
Pinecones
Will only germinate
In fire
When the undergrowth
Is cleared
Conditions are right
For new growth

Perhaps pain is our fire
Grief is our fire

If we block pain
Where does it go?
Does the fuel build?

I wonder if the tall pines
Fear fire
Would they avoid it
If they could

Perhaps suppression
Is not the answer

Perhaps we can change
Remain present
Acknowledge pain
As normal
As joy

Perhaps if I
Step into the fire
I can remain
Present
For you

And you will be
Less alone
Less afraid

I open my doors

Let the fire burn

poem written before 2009

CDC guidelines for treating chronic pain: https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf

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March for people

My daughter and I marched yesterday.

She decided to come home from college for the weekend, planning to leave Saturday night. I decided not to go to the Seattle Womxn’s march, but do the Port Townsend one and asked her to join me.

We went out to breakfast and then to our small downtown. I no longer have television and look at news sites daily though a bit erratically, so neither of us had a pink hat. I wore my Mad As Hell Doctors t-shirt, my lab coat from working at the National Institutes of Health with the National Cancer Institute Patch, my Rotary name badge and pins gathered from going across the country trying to get medicare for all, single payer health care, from 2009 until now.

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Four bus loads went from our county to the Seattle march. We heard that the Bainbridge ferry was FULL. That is, they couldn’t not take any more walk on people. Another thirty people or more flew to the Washington DC march. And in Port Townsend, my guess is that we still had 200-300 people, women, men and children, people in wheelchairs, babies, gay, lesbian, straight, bi, trans, that marched from a small park downtown to the Haller Fountain. Galetea, naked statue at the fountain, sported a pussy hat.

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Our local organizer spoke and our House Representative, Derek Kilmer.

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Older women spoke about demonstrating over and over in their lives. A friend of mine called me up to help her sing Holly Near’s Singing for Our Lives, making up new verses on the fly. They invited people to speak.

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I spoke: “I am one of your local doctors. I want to be able to treat anyone who comes to my clinic. We are one nation: health care for all. No discrimination: medicare for all.”

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Home then, and tired. My daughter has decided she wants to learn guitar, to play while people sing. I taught her basic chords and basic strumming. We sang Jamaica Farewell. She picks it up immediately, after all of those years of viola. And she will take one of my father’s guitars back to college.

And this is amazing: https://www.nytimes.com/interactive/2017/01/21/world/womens-march-pictures.html?smid=fb-share

Blessings all around.

Physicians for a National Health Care Program: http://www.pnhp.org/

https://dailypost.wordpress.com/prompts/successful/

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Bruise, muscle and bone

I asked an older patient recently, “What is a bruise?”

She thought about it and said, “I don’t know.”

A bruise is blood, bleeding. Old blood changes color and is reabsorbed by the body as it heals. But where does that blood come from?

Any tissue in the body can bleed. Even a tooth, if broken into the center.

So what is bleeding for MOST bruises?

Muscle. Muscle, muscle, muscle, tendon, ligament, fascia, occasionally bone if broken and internal organs can bleed as well.

Somehow we entirely fail to teach this, at least in the US.

If you fall, or like my mountain biking daughter, hit something, your body will bleed. I tried to train the mountain bike team to carry an ace wrap and use it any time they hit something hard with an extremity. I pretty much failed. Why do I want an ace wrap and why use it immediately?

Trauma or hitting something hard causes bleeding. The more the muscle and tissue bleeds, the more swollen it gets. Usually the peak of bleeding and swelling is at about 48 hours after the injury. By then the body is sending immune system cells and repair cells to fix the trauma. It is swollen, red, hot, inflamed and painful! If we ace wrap our ankle or foot or elbow immediately, the bleeding stops faster. Wrap it, ice and elevate to keep the bleeding down. The torn muscles are held in their normal position, the bleeding stops more quickly, there is less swelling, less redness, inflammation and pain!

Our acronym is RICE:
Rest
Ice
Compression
Elevation

There are things that you can’t ace wrap: don’t ace wrap your neck or ribs and if it’s bad trauma to the head, neck, chest or abdomon, go to the emergency room! But even then, ice and compression help. First check airway, breathing and circulation, that the heart is beating if you happen on a trauma. But then try to use pressure on bleeding.

Do not put heat on a bruise for that first 48 hours. Why? It bleeds more and swells more. The exception may be if you do much more exercise than usual without a localized injury: hydrate, stay away from alcohol and a hot tub or hot bath may help. The hydration and hot water help the muscles relax and wash out the CK, creatine kinase, the protein from tiny muscle traumas that make us “stiff”.

The I in RICE used to mean ibuprofen as well. However, ibuprofen and aspirin and naprosyn are all blood thinners, so they may help with pain and inflammation, but may make the bruising worse. Acetominophen is not a blood thinner and also doesn’t do as much for inflammation, but it may be a better choice. It does help with pain.

In her third year of mountain bike racing, the Introverted Thinker had a quarter size bruise on her knee after a race.

“Are you going to do anything about that bruise?” I asked.

“No, it’s small.” she said.

“Ok.”

Two hours later: “Mom? Would you look at my knee?” Now the bruise is the size of an orange.

“Hmmm. What are you going to do about that?”

“I think I might ace wrap it and ice it and put it up for a while. Where is the ace wrap?”

Good plan. It didn’t get any bigger.

I see the handouts from the emergency room given for back pain and they are terribly misleading. It shows the spine and talks about the discs. 99% of the back pain I see is NOT a disc: it is the six layers of back muscles, and complex web of tendons, muscles and ligaments that hold the spine together and let us move in very complex ways. I pull my Netter Anatomy out daily in clinic and show people the six layers of back muscles.

What happens after a muscle is torn and bruised and bleeding? The muscle cramps up to stop the bleeding and attempt to keep from being torn more. No, I don’t like muscle relaxers much as medicines and they are useless long term. For sleep only right after injury. I am not talking about major trauma, but back pain and injuries.

If the muscle heals in the cramped position, it won’t work right any more. It can form scar tissue. It takes about six weeks for a muscle or ligament or tendon tear to heal and during that time we need to gently stretch the muscles without tearing them, so that they heal in the right position. Once they are healed in a scarred position, it’s more work to rehabilitate them, but it can be done. Physical therapy, massage therapy, chiropractor, acupuncture, but the most important work is done BY the patient, not TO them. I can’t fix it with pills. Yes, it is work.

You can bruise bone too. Ow. The surface of the bone is living cells and the bones are continually torn down by osteoclasts and rebuilt by osteoblasts. The bone can be bruised without breaking. Again, 6 weeks to heal, little kids faster and 90 year olds kind of slow.

Take care of your muscles, ligaments and tendons, and they will take care of you.

 

I took the photograph on the first Mad as Hell Doctors tour for health care for all in 2009. I will be marching again today:Β  WE ARE ONE NATION! HEALTH CARE FOR ALL!Β NO DISCRIMINATION!Β  MEDICARE FOR ALL!

 

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stomach flu

On call for my patients, I get a call about flu.

The spouse sounds worried. I speak to the sick person.

“Do you have a fever?”

“Yes, 100.6. I am throwing up and I don’t want to eat.”

“Do you have muscle aches?”

“Not really. I know I need to drink water.”

“Are you coughing?”

“Not really. Not much.”

“Not very congested. Do you have diarrhea?”

“Yes, lots. And my stomach hurts when I eat.”

People often say “flu” meaning “stomach flu” which is not influenza. “Stomach flu” is gastroenteritis, another set of viruses entirely. It could be a bacterial food poisoning, but in 17 years in my rural town, I have seen a total of two food poisoning bacterial infections. Most here are viral.

“Is there blood in the diarrhea?”

“No.”

Viral, then. Blood in the stool is more likely to be bacterial.

The important thing is to stay hydrated. If the person gets too dehydrated, they tend to just keep throwing up and may need iv fluids. To keep them out of the emergency room, I give the following recipe:

One quart of water
one teaspoon sugar
A pinch of salt
(with or without a pinch of baking soda)

If the person is quite nauseated, try drinking just a tablespoon every 15 minutes, with a timer. The electrolytes and sugar help the fluids absorb. Small amounts are easier to absorb and less likely to come up. If they keep throwing that up, go to the emergency room.

“I’m not eating.”

That’s ok. A day without eating won’t hurt you unless you are starting very underweight. Get the fluids in first and then you can go on to chicken soup and try some crackers.

Gatorade or flat ginger ale or pedialyte contain electrolytes too, but the home recipe is fine. And for small children, regular or pedialyte popsicles, because they can’t really drink them quickly.

Most people will recover on their own, especially if they stay hydrated. We don’t tend to try to stop the diarrhea, it’s better just to hydrate people to keep up. If someone is immunosupressed, on chemotherapy or with HIV or after a transplant, they may need hospitalization.

Does the picture look upside down? A bit nauseating or disorienting? I took it in Portland, and yes, it’s upside down.

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Influenza and lung swelling

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. 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. 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 grabbed 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 spasms. Cough medicine doesn’t work 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!

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Coming soon: The Unaffordable Health Care Act!

Coming soon in the United States!

Aren’t you sick of the Affordable Care Act? aka Obamacare? Time for a new administration and time to get rid of Affordable Care. We don’t want that! Competition, Corporations and Profit First!

Call Mr. Future President Trump, call you congress persons, call your senator, call your representative, call your state ones. Stand up and be heard, US Citizens! Tell them you are all for the Unaffordable Health Care Act! We can kill more small businesses faster! We can make doctors and nurses quit by age 50! We can have more people turn to addictive drugs for numbing and comfort!

Come on, US Citizens! You voted! Now call! The Unaffordable Health Care Act! brought to you by an all conservative all corporate all discriminatory group of unbelievably rich congresspeople and your stinking rich and suing everyone future president.

Or you could say you want Medicare For All! Hey, one system, one set of rules, all US citizens have care, we could start small businesses, business might return to the US since they don’t have to pay more and MORE and MORE for health insurance, wages would go up instead of yearly decreases in health care coverage….nah, US Citizens, you wouldn’t want that, would you?