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Mergansers

These are some of the creatures that I saw last summer at Lake Matinenda. A whole family of mergansers swam around the point in the early morning. I was drinking tea and writing in the very early morning. Suddenly they startled at something in the water and all rushed up on the rock ten feet from me. I froze and when they didn’t notice me, I slowly picked up my camera.

What were they scared of? There are pike and lake trout and otters…

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Rain on water

My sister wrote Rain on water and posted it on everything2.com in 2009. Here: http://everything2.com/title/Rain+on+water

She was writing about going to Lake Matinenda. Our family has had land with cabins since the 1930s and now the fifth generation has gone there.

My sister died in 2012. I wrote my own version while I was there last summer.

____________________________________

What are you doing?

nothing

outwardly nothing

Inwardly, I am on a journey. I am back at the lake. It’s been three years. I am at the lake when the family is not there. I take old friends who have never been there. One knew my sister as I did and has known me for thirty years.

He and his wife and his six year old love the lake. And the six year old wants freedom as we all want but there are rules and you must wear your lifejacket on the front rocks until you can swim and can swim a certain distance and we never get in the canoe when it is on the rocks, it must be in the water or the canoe will be hurt and my uncle’s shade is over my shoulder and I can hear him yelling about the canoes as his parents yelled at him. The birchbark canoe that he and my mother destroyed still awaits repairs. And I demonstrate how to tip a canoe over when we go swimming and how fast it goes. “You may try it, but first you must practice jumping in the water. Do you want to?” No, he shakes his head, no, the small canoe went over so fast.

They leave and I am alone. I am not alone. The dead are there, their ashes, their words in the log, their voices in my head, their heights marked on the wall of the Little Cabin, my sister’s clothes, a marker for my uncle, my grandmother’s bed has been taken apart and is now a bench and I grieve about change and loss but it goes on. My sister is a sea otter but there are no sea otters at the lake and she is at the lake with me because she said, “How will I find you?” and I told her how and she was satisfied. No sea otters, but there are river otters, they come, a family, three, playing and fishing. I sing to them, Pie Jesu and they watch me curiously and go back to fishing and I think of my father my mother my sister and that I think they would be happy to be river otters in the lake together and fishing. I am with them almost and crying. My grandmother is a white pine and in the mink, my grandfather is a dragonfly, my uncle is the snapping turtle, I wonder what my friend’s son is, dead at 22, and the next animal I see is a merganser, the hooded merganser with two babies and she is leading me away from them while I am in the canoe, they are hidden I know about where and she circles back to say that now they can come out and are safe and I think yes, that would be right, a child who grew to a young man and was lost, he might choose to be a mom next caring for these young and careful and nurturing them, protecting them, hiding them, leading danger away.

Loons call and I answer and my voice lessons have helped my loon calls, I can hit the high notes now. A long conversation with a loon with me in the blue canoe and the loon wondering, do I have a loon trapped in my boat or am I in fact a loon, yes, I think I am, I will be a loon not a human any more

I can’t swim for long, not yet strong enough, the taste of the water is ingrained, layers of memory back to five months old and beyond, in the womb, has the lake marked my dna in three generations, I don’t know but I am in the water I am of the water I am water tears and water

written 8/29/15

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I will marry only he who defeats me in battle

he
I am not really that attached to gender.
I’ve always thought that love is love
and who cares what birth sex or chromosome arrangement
people have
since nature’s diversity
is beyond insane

marry
I am not sure I would marry again
there is so much attached to the archetype
of a married couple
and no two are alike
in their conscious
much less unconscious
and then project the unconscious expectation
it makes me tired just thinking of it

battle
I agree that we are all fighting a battle
but I think it is always with ourselves
avoid avoid avoid
things that we fear
when we should go towards them
and embrace them
for our fears are the demons
we’ve chained in our unconscious

defeat
what is defeat?
loss of money?
loss of power?
the only defeat I have
is when I try to avoid myself
my true self
my dark self and my light self
there is no defeat
except my own failure
to admit my true self

I love who I love

whether they love me back

or not

 

I took the title from here: http://everything2.com/title/I+will+marry+only+he+who+defeats+me+in+battle and published there as well

 

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Prior authorization: call for comments

The Washington State Medical Association has called for comments on prior authorization rule making for insurance companies. https://wafp.net/prior-authorization-rulemaking-oic-call-for-comment/

Here is my reply:

I have a small solo family practice clinic. My business plan was arranged to spend more time with patients. I have an office manager and no nurse, no back office.

Thus all prior authorizations are done by me, with the patient in the room. Often patients have talked to their insurance company the day before and have been told “your doctor’s office needs to call us”. More than half the time, when I call, we are told that the patient’s insurance company does not cover that service. The patient says, “But I talked to your company yesterday.” The insurance representative responds: “I only talk to physician’s offices, that is another part of the company that speaks to patients.”

This is triangulation, where in the “standard” office, the patient has called their insurance. They call the doctor’s office as instructed by the insurance. The doctor’s office requests prior authorization. The insurance says it is not covered. The doctor’s office notifies the patient, who then assumes that the doctor’s office did something wrong, not that it’s not covered.

This is unacceptable.

I have stopped telling insurance companies that I am face to face with the patient, because some representatives say “I am not allowed to talk to patients, take me off speaker phone.” I document the name of the insurance person in the chart, the length of time for the phone call and I bill for time: counseling and coordination of care. Review by coders say that this is legal.

I suggest that every WSMA physician pick one day to call a prior authorization themselves with the patient present. This would reduce the insurance company triangulation.

I think that insurance companies should be required to tell a patient if a service is not covered, and not be allowed to say, “have your doctor’s office call us” for a service that is not covered.

Feel free to send YOUR comments to the WSMA! https://www.insurance.wa.gov/secure-forms/rules-coordinator/

I like slugs better than health insurance companies.

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Does back pain mean a disc?

Does back pain mean a disc?

Does sciatica, pain down the sciatic nerve, all the way down the leg, mean a lumbar disc is out of position and you need back surgery?

Ninety nine times out of one hundred: No.

No? What? Really? Doesn’t back pain and sciatic pain mean a disc is pressing on the nerve?

Nope.

Sciatica means that the nerve is annoyed. It is sending pain signals. It can be irritated and inflamed anywhere along the entire path of the nerve. When the nerve is inflammed or there is surrounding inflamation, the nerve sends pain signals.

But… if it is not a disc, WHAT IS IT?

Muscles that are injured, inflamed, irritated, contracted or torn, that in turn put pressure on or inflame the nerve.

The sciatic nerve is made up of multiple nerve roots coming from the spinal cord: L3, L4, L5, S1, S2, S3. And then variants. The nerve roots bundle together and then dive through a group of muscles and go down the back of the leg: deep in the muscles. Why deep? To protect this very big, very important, bundle of nerves. Branches veer off and innervate muscles and bone and tendon and fascia, all the way down to the toes. There is not a spinal column in the leg, to protect this nerve.

It dives in between the superior gemellus and the piriformes muscle, deep in the buttock. Under the gluteus maximus and the gluteus minimus. Then it goes down the leg, under the semitendonosus muscle and the biceps femoris muuscle, the big hamstrings.

Now, let’s go back up to the low back. Why does it hurt? With or without sciatica? There are six layers of muscles in the back, all way smaller than those hamstrings. The top is the latissimus dorsi, down 5 more layers to the small longus and brevis rotares muscles, which connect each vertebral bone and allow subtle and complex movements of the spine.

What happens when a muscle is torn or injured? People look blank in clinic when I ask. I say, “Think of a piece of steak, what happens when you cut it?” They still look blank. “It BLEEDS, right?” When a muscle is torn or injured and bleeds, it and the surrounding muscles cramp up as much as they can, to try to prevent further bleeding and tearing. If it is an extremity, ace wrap, elevate and ice, as soon as possible, to slow the swelling and bleeding and pain. If it is the lower back muscles, ice as soon as possible and applying pressure won’t hurt. No heat for 48 hours since muscle bleeding and swelling and inflammation usually peak at 48 hours. After 48 hours apply heat, then gently stretch, then ice after stretching.

Think of the muscle fibers as torn. They take about 6 to 8 weeks to fully heal. You want to stretch them and rehabilitate them without tearing them in that 6-8 weeks. You want every muscle to be fully functional, to be the right length, to not heal shortened or scarred. Get those fibers working again…

….or….

But doctor, my back has been hurting for FIVE YEARS!

Then it will take longer than 6 to 8 weeks to rehabilitate, retrain the muscles, gently break down the scar tissue, get it all functioning. Your muscles are doing their best. They told you they were hurt and you need to listen to them.

Covering it up with ibuprofen or alcohol or any number of substances or trying to ignore what your muscles are trying to tell you is a bit counter productive, don’t you think? Pain is information. An advil can help with the pain, but it does NOT fix the problem. “Drug me so that I can go on ignoring it.”…. uh, no. That is not ethical and it also doesn’t work.

And just think, if those back muscles continue tighter and tighter… they are constricting and pulling on the spinal bones.Β  They pull on those bones and then a disc might be thinned or crushed and might protrude and then press on a nerve. And then for surgery, what do they do to get to the disc? Cut through the six layers of muscle….

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Does pain mean danger?

Does pain mean danger?

From a physician standpoint, sometimes the answer is “No.”

One example, sent by an alert friend, is a lump on the back of the neck, with pain radiating downwards.

This could be an abscess or an infected cyst, but since they didn’t mention infection, it is most likely an enlarged lymph node. This is one example where the doctor or nurse practitioner or psychic healer will look at it, say “Does it hurt?”, poke it and then be all cheerful while you wonder WHY they have to poke it* after you say, “Yes, it hurts.”

A newly enlarged tender painful lymph node is usually a reactive lymph node. It is swollen with cells from the immune system and is trying to heal something in the vicinity. A cut, irritated acne, a cold virus, that shaving accident, a low grade infection, an ear infection. Usually I talk about it and recheck it in two weeks.

The lymph node that will make your healthcare person worry is the one that DOESN’T hurt. A slowly or quickly enlarging lymph node that is not tender is worrisome for lymphoma or for metastatic cancer. Once it gets to 1 centimenter, I am calling the surgeon to consider doing a biopsy. We have lymph nodes throughout our body, but the ones that we can feel on the surface are only in the neck, the supraclavicular nodes, the axillas (aka underarms) and groin. The rest are under bone or muscle, though they can show up on CT scan or xray: enlarged mediastinal nodes along the great vessels and trachea in the middle of the chest.

So pain does not always correlate with the level of danger of an illness. The reactive nodes hurt because they swell quickly, and they usually go down quickly as well.

*They poked it to be sure that it is not fluid filled, that it is firm but not hard and fixed, so not an abscess or cyst, and doesn’t feel like a cancer.

I took the photograph last night with my cell phone, during a rare thunder and lightning storm here… beautiful.