by

A weight loss drug complication

People are ordering versions related to semaglutide (ozempic) and dulaglutide (trulicity) from compounding pharmacies for various reasons. Their insurance may not cover the prescription or they may actually not qualify by their weight and complications. Here are the guidelines from the American Gastroenterological Association: https://www.aafp.org/pubs/afp/issues/2023/1000/practice-guidelines-medications-weight-loss.html. Those criteria: a body mass index (BMI) greater than 30 kg per m2 or BMI of 27 kg per m2 or greater with associated complications (e.g., hypertension, diabetes mellitus, and hyperlipidemia).

I have already had requests in clinic for a prescription sent to compounding pharmacy. I am refusing to send prescriptions out of state or to compounding pharmacies, because of the FDA warning. Here: https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fdas-concerns-unapproved-glp-1-drugs-used-weight-loss. There are a bunch of issues: some compounding pharmacies are not using the FDA approved medicines, they are using something similar, but not the same. Also, the medicine does not come in the pen that injects a controlled amount. People have to draw the drug up and inject it. Some have injected ten times the amount that they should and have been hospitalized. It’s also worrisome that the compounding pharmacies, unlike state-licensed pharmacies, do not have to report complications.

A recent patient has deteriorating kidney function, with his creatinine jumping from 1.10 to 1.58. Creatinine is produced as a waste product by our cells and the kidneys need to clear it. His 1.10 was normal but the 1.58 is high, indicating the his kidneys aren’t clearing well, and that was only a six month interval. He is taking compounded semaglutide and compounded testosterone, with some online approval. That is, he did not get a prescription from our clinic. He started the semaglutide five months ago. The testosterone has been for years. “Stop the semaglutide and we will recheck your kidney function in a month.” His creatinine drops back to 1.10. Acute renal failure is listed as an uncommon side effect of the FDA approved semaglutide, but we don’t know if that is what he’s getting. I tell him the good news about his kidney function and say, “I think you should stay off the compounded drug.” I have not seen the same thing with the FDA approved semaglutide.

It’s complicated, isn’t it? We picked up the problem because he is on other medications and I do yearly labs on people who are on prescription medicines, to check whether their kidney or liver function is deteriorating. Almost all drugs, prescription or over the counter or supplements, are metabolized by either the liver or the kidneys. I only know of two that are not absorbed and not metabolized.

For the Ragtag Daily Prompt: pristine. I would like a pristine pill free body for as long as possible. Ok, I took one tylenol last week and I’d be dead three times over it wasn’t for penicillin.

by

Why mean?

Why do people do that smiling mean thing? Where they are teasing too close to the bone, meanly, with a smile. If you object, then you are labeled as someone who can’t take a joke or who has no sense of humor. How do people handle them? I put them on avoid and do not want to be around them. But really, what motivates them? Power? Humiliate others to feel better about themselves? What a very sad and pathetic way to go through one’s life.

This is related to me thinking about what people think about. I think about what motivates people a lot and why they do what they do. This, apparently, is NOT what most people think about. My curiosity about people dates back to being a very small child and being passed from household to household because my mother had tuberculosis. I decided that adults did not understand children and that they loved me but didn’t understand that babies should be kept and loved. My sister was born when I was three and I told people that she was MY baby. I was determined to take care of her. Alcohol continued to make the adults in my household unpredictable and sometimes dangerous, at least emotionally.

My mother could charm a room and all visitors, but sometimes she would talk about them after they left. My family tended to ignore me if I was reading, because I really did not listen if I was deep in a book. Books were an escape and a safe place. People would have to call me three times to get me out of one. But sometimes my brain would click me out and I would listen to the conversation. My mother would talk about people’s motivations and was often quite negative and not nice. Interesting, but not nice.

When I realized that most people don’t think about others’ motivations most of the time, I felt rather freed and enlightened. I promptly ran into not one, but two mean people, at different sites. I do not understand meanness. I worry that it will be in the White House soon, as well. And what, that meanness wants to annex part or all of two other countries? Is this fascist envy? That’s what I think. So there.

The photograph is Sol Duc in 2022.

For the Ragtag Daily Prompt: mean.

by

Thinking about this and that

I am thinking about thinking. What do people think about most of the time?

This partly comes from my ex. He thinks out loud a lot, an external processor. My daughter and I wanted to know what he thinks about. My son asked. “Dad, what do you think about?”

“Golf.”

“Golf?”

“Yes.”

“Anything else?” says my son.

“No.” says my ex.

I have no idea if this is true or not. Sounds hella boring to me, honestly, but he seems entirely happy with it. De gustibus non est desputandem.

I had lovely winter holidays, celebrating EVERYTHING. I went to my son and daughter-in-law’s out east. My daughter and her significant other came out and we did presents on December 27th. Then we went to see my two aunts and uncle for a couple days. They are in their 80s and delightful! Back to my son’s and we saw my kids’ remaining grandparent, my ex-husband’s father’s significant other. Got that? And one of my kids’ paternal cousins with her significant other. I stayed with old friends for the last three days, which was also delightful. We went to the Smithsonian American History Museum and read every single thing. But only in two exhibits because that place is huge.

Now I am back to my current home and hello, cat! Back at work as well. More about that next time. The sands are shifting and I may be in another clinic. Monday a patient asked if I am their new doctor or am I a floater? I said I prefer “Temp” to “Floater”. She laughed.

For the Ragtag Daily Prompt: think.

by

All home

My daughter and her significant other arrive two nights ago and we open packages and stockings yesterday morning. Lots of laughter and chocolate and much contentment. Now I have a climbing harness in pale green! We did not climb yesterday, I was too tired. We did go for a park walk on an old golf course and had a delicious dinner. It is lovely to all be gathered here and trading stories and jokes and family silliness.

Today I am up early. We will drive down to see my two aunts and my uncle. The great aunts and uncle to the kids. A very delight!

For the Ragtag Daily Prompt: contentment.

by

Today and tomorrow and the day after

Good morning! I hope you are having a happy day today! I am up and having tea and reading and listening to music, waiting for the rest of the household. They may be a while.

I arrived at my son and daughter in law’s on Sunday. The glitch was that my son and I couldn’t find each other in the pick up area and got frustrated. Turns out that I was at National Airport and he was at Dulles, which does make it more of a challenge. I took my bags and hopped the metro out into Maryland, and they picked me up at the station. Whew.

We are talking, eating, wrapping things and climbing. We went to their climbing gym yesterday and I did a respectable job on some 5.6 and 5.7 climbs. Today my arms want to fall off. Last year my climbing style was panicked sloth. This year I am much better since I have been going to my climbing gym once a week. Arm muscles! How amazing!

We are going to continue wrapping today. My daughter and her boyfriend arrive late tomorrow so we aren’t going to tear paper off stuff until Friday morning. My inner little kid suggests that we unwrap today, wrap it back up, and do it AGAIN on Friday. This waiting frustrates her! Oh, well. No, dear, we aren’t going to do that.

Have a lovely today and tomorrow and day after tomorrow!

For the Ragtag Daily Prompt: today!

The photograph is Elwha looking up at the Christmas stick last year. I miss him!

by

Honey

Work is being a bit of a difficult place. I think that if a clinic is has two new providers with one new medical assistant, there should be some formal support in place. Not the manager of multiple offices sticking their head in the room with the three of us at computers and saying, “Everyone happy?” Um, no. This came to a head two days ago. Then yesterday I am asked to write up what I said to the manager.

No. I don’t think that is appropriate. If they have formal evaluation forms, fine. If they want a biweekly formal meeting, fine. If I ran the zoo, I would be sitting down biweekly with the job description to say, “This area is going well, this part needs some more attention. What is going well from your perspective and how can we communicate better to help each other and the patients?”

In fact, in my very first practice in 1996, I asked for a meeting with my receptionist. They had one for each pod of 2-3 providers. She was so freaked out by it that she brought the office manager, much to my surprise. I didn’t care and just said, “What is going well, what isn’t, where are the communication gaps, how do we fix them?” The receptionist looked at the office manager, said she had been scared that I was going to yell at her, but since I wasn’t, she let the office manager leave. We were fine after that. I just want a well functioning team and I am happy to help build it.

So, after thought, I am going to refuse this write up and ask what their HR process is and say that I am not satisfied with the office support and that it is quite unreasonable to leave two providers new to the clinic to guide and train a new medical assistant.

The Ragtag Daily Prompt is honey pot. That bring up this delicious and quite naughty Taj Mahal song, ooooooo. As my mother would say, you catch more flies with honey than vinegar.

by

Climbing the walls

When my father died, he left me a will written more than 40 years earlier. He and my mother and my maternal grandparents were all pack rats. It was a house and two barns and ten years worth of some mail. A mess.

After working on it for a year, I felt like I was in knots and couldn’t relax. I was quite sick of counseling and wanted to do body work instead. I found a massage person and worked with him for over a year.

On the first visit he talked to me and then had me stand and walk around. “You are head forward and your toes are gripping the floor.” “I am not!” I said, lifting my toes. He was right, though. I had to relearn how to walk for two weeks, lifting my toes up.

I went to see him once last spring, knotted up again. I thought I was much better at unknotting during the work. I asked, “So am I pretty relaxed?”

He laughed. “You’re NEVER relaxed. Your baseline is 7/10 but you notice that you are tight when you get up to a 9 or 10.” He said that relaxed was 1-3.

I was hurt and annoyed. All that work and he’d never said that and never given me tools. I tried to contact him by email but he either didn’t remember what he said or just wouldn’t deal with it.

I was grumpy.

Meanwhile in clinic, I was teaching the breathing technique to try to relax, to go from sympathetic fight or flight, to parasympathetic. Breath in for a slow count of 4 seconds, then out for a slow count of 4 seconds. I thought, well, I should do it more too. I decide that when I wake up, I will do the breathing technique.

It promptly put me back to sleep. I have used slowing my breathing to go to sleep. I also had three years in college and after where I did daily zen meditation, facing the wall, on a zafu, for forty minutes. Add my flute playing and singing in chorus for the last 24 years and I can do the count way past four. My mind, however, is a very busy place, and meditation often felt like letting a cage full of crazy monkeys out. They all wanted attention. My understanding of zen is that I am supposed to let the monkeys show up but not hold on to them, converse with them, or let them hold the floor. Return to the breath.

When we wake up, we have a cortisol burst in the morning. It gets us going. I am pretty sure that I have some adrenaline too. The slowed breathing calms that right down. According to the pain clinics, twenty minutes of slowed breathing calms almost everyone down into the parasympathetic state. I don’t think that the high Adverse Childhood Experience people are used to parasympathetic. Honestly, looking at the movies and television and video games, I think our culture is not used to it either.

The breathing in the morning is working. My neck and shoulder muscles are more relaxed (in spite of computer use). Maybe I am down to a 5/10! That would be huge progress, right?

And my muscles love the climbing walls, too. Not that I am that good at it, but my muscles really like the intensity and focus. It is so different from clinic, where everything is focused on listening to the patient, typing as they talk, watching, sensing, trying to get a handle on what is happening with them. The wall is like clinic in focus, but my whole body is involved and there is lots of reaching and stretching out of that contained focus.

Sol Duc seems to be good at slow breathing. Cats go from 1/10 to 10/10 in just a heartbeat, or that’s my impression.

There is no alabaster in this house. Not a bit. Perhaps I will meditate on that.

For the Ragtag Daily Prompt: meditate and alabaster.

by

Content

I never do know where a poem is going when I start it. Usually I start in the dark. To my surprise, those poems will end in the light. Apparently the reverse is true too.

Content

At the moment I am feeling content
deeply content
with monsters

At the moment I don’t need more
then this
me
a few friends
and all the monsters

I can’t fix the monsters
healer, right
the people come
over and over
and won’t admit
their monsters

the monsters sit on the floor
of the exam room
clinging to the person
chained to the person
the monsters wail and cry
while the person
ignores them

It has taken me all these years
to let go of anger
fury
rage
that almost no one
admits to monsters
or tries to heal them

Except the addicts, drunks, crazies
they see them too
many try to destroy their vision
with alcohol or drugs
or persist on telling others
about the monsters
until they are drugged

Yesterday I look on line
for local music
not bluegrass
thinking that I would like
to find a place with grown ups
quiet

I think, how silly I am
to look for grown ups in a bar
and then I try to think
of where to find some grown ups
and I think THERE AREN’T ANY GROWN UPS
it’s all just children
who’ve grown big

I do not like drama
there are no movies
that I want to see

I like clinic
where I try to help a little
sometimes a lot
sometimes a person might remove
one knife
one chain
one arrow
from their traumatized
terrified
bleeding
monster

And really
that is why I am here
and that is all that I can do

__________________________

For the Ragtag Daily Prompt: journey.

Meanwhile, rat joy: https://www.bbc.com/future/article/20241128-i-taught-rats-to-drive-a-car-and-it-may-help-us-lead-happier-lives.

by

Impersonal Day

After I post my story about nuisance on Thursday, I have a bigger nuisance show up. I get ready for work, tell my cat to have a lovely day, get in the car, open the garage door, back out and press the button to close the door.

It doesn’t close.

I try again.

It won’t close and is wonky at the base.

Dang it. I pull back into the driveway and investigate. Two of the wheels are out of the track and it’s obviously broken. There is a button lock between the garage and the house, but the garage also has stuff in it from the owners, including tools. I get a chair, stand on it and am clear very quickly that I can’t fix it.

Next I call work and apologize, but I can’t secure the house and can’t leave. They cancel my day. I have to dig around for the rental number but I find it. I call once, text, wait a bit and call again. He calls back and sends a person over.

The person take about half an hour to get there and he can’t fix it. They call a garage door company.

So now I am cooling my heels and stuck here. My kids all have wishlists for Christmas so I get everything ordered and sent off to my son’s. They will be rather inundated with packages since one Amazon order generated 7 packages all on different days. Goodness. I do some cooking, read a novel, and wait.

At 3 pm I let the rental person know that I am still waiting.

At 4:15 two garage door people show up. The wire at the opposite side from where the wheels are off is all tangled and off the rails. They have some specialized tools and it is fixed by 4:45. Part of the time is just them waiting for payment permission to go ahead with the fix. The garage door now opens and closes! I thank them and they head out. Turns out that their boss lives on my street.

A friend says, “You called in a personal day.”

“No,” I reply, “I called in a stuff goes wrong day. A very impersonal day.” My work did not give me any grief at all about it. We were already shorthanded but what could any of us do? Apologies to any patients who got canceled! We all do the best we can, right? Things break down sometimes.

For the Ragtag Daily Prompts: shopping and nuisance.

I deleted some past posts to make room but apparently not enough, sigh. Another bit of a nuisance. I can post a phone photograph but not one from my bigger camera.