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Fear stands

For RonovanWrites Weekly Haiku Prompt #79, the words are crystal and hope….

fear stands strong don’t look
crystal water reveals rocks
open eyes give you hope

 

I took the photograph in 2012, when my sister was referred to hospice for breast cancer. I took three trips to see her before she died. She was still very engaged with everyone on the second trip. But when she was not talking to anyone, her face was different. She was looking at eternity. She knew that I could see her doing it, because we knew each other so well. She did not want to talk about it to me until my last visit with her in this life. I felt so blessed and honored when she did talk to me, and I hope that she feels loved.

 

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Fraud in medicine: FAXMANIA!!

All right, the latest trend in the complete insanity that is the United States Medical Corporate Black Hole Eating The American Dream: FAXMANIA!!!!

I am a Veterans Choice rural provider. Well, I thought I was. But turns out even though the VA keeps calling me to accept new veterans who are more than 40 miles from the nearest VA, they have not paid me for one visit in 2015. And I did between 20 and 30.

Because, you see, even though they have me listed as a Veterans Choice Provider, the paper work is SPECIAL and it has to be PERFECT and we have to fax EVERYTHING.

So I have to fax every single clinic note to Veterans Choice. Where, presumably, they lose it and have plausible deniability. Also, when a patient comes to see me, they are only approved for ONE NEW PATIENT VISIT, TWO FOLLOW UP VISITS, WITHIN THE STATED DATES, which is two months. Then I have to fill out a form and send it to Veterans Choice, who sends it to triwest, to get approval to continue to be my patient’s primary care doctor FOR ONE YEAR ONLY. Then I have to remember to do it again. AND I have to fill out a form to send to Veterans Choice, who sends it to triwest, for every single referral or test more complicated (read: expensive) than an xray AND for labwork AND don’t forget to fax a copy of every clinic note to Veterans Choice so they know I did it AND now for one patient’s medicine, I have ALSO fax a copy of every note to his VA PRIMARY CARE DOCTOR so that she will refill his pain medicine because: Hell if I know, apparently it’s EASIER to fill from her than me because the VA has no frigging idea who I am.

And the Veterans Choice 40 mile rule? We have two patients now from Whidby Island. They have to take a ferry to see me. Yes, they can bring a car on the ferry. Yes, they can get here except when the ferry is canceled for very low tides or weather….Yes, it’s insane.

Meanwhile, this note from the State of Washington Health Care Authority, aka medicaid: “The Contractor shall require that when subcontracted provider organizations with certified EHRs see an Apple Health Managed Care enrollee, they send a care summary (CCDA) from the providers EHR to the WA Link4Health Clinical Data Repository beginning no later than February 1, 2017.” Translation? Oh, we have to send bloody proof that we saw the bloody patient in the form of a CCDA electronically OR ELSE! OR ELSE WE ARE BREAKING THE LAW! They wouldn’t want to fire us but you betcha they would love to fine the hell out of us. Note: This requirement only applies to provider organizations who have already invested in certified EHR technology.

Hi, Big Brother.

Now, fax is HIPAA compliant, as long as we include the cover disclaimer that IF WE SENT IT TO THE WRONG PLACE SHRED WITHOUT READING OR YOU WILL BE STRUCK DEAD BY LIGHTENING FROM THE SKY GODS AND/OR THE ORBITING LASER HIPAA POLICE.

And meanwhile I have lab order forms for the three labs in town (all completely different and even with different panels) and one in Sequim, also 6 different forms for 6 different places for xrays, CT scans, MRIs, a form for the Vascular imaging, a form for cardiology, different ones for each physical therapy office. Now the DMV disabled parking form must be accompanied by a prescription on legal Washington State prescription paper saying yeah, he is disabled. Why use one piece of paper when you can require two?

When I fill out lab orders for the local hospital, the patients sometimes say, “Can you fax that over?”

“Yes,” I say, “but they lose 50% of them.” No, really. We fax them and keep a copy and then the patient goes in and the lab calls and says, “We don’t have the order.” I am not sure if they are “lost” or just in a pile to be entered into the TIME SAVING ELECTRONIC MEDICAL RECORD COMPUTER SYSTEM THAT MAKES EVERYTHING FASTER AND MADE US PAPERLESS EXCEPT FOR THE TEN MILLION FAXES DAILY. “You are better off picking it up and handing it to them, or I can mail it to you.” The other day a patient asked if that was malice, since I am not in the hospital system. “No,” I said, “I think they have laid people off until there aren’t enough and the corporation dumps the long timers that know stuff and cost more.”

Once I was working on a holiday Monday. I had a patient who I thought had a new arrythmia. I called the hospital and asked the tech if we could do an outpatient ECG on this holiday.

“I don’t know.” the tech said.

There was a silence. I wondered if the tech would ask someone in authority.

“I’m new.” said the tech. “They’ve laid a lot of people off.”

Someone in authority WAS present. “We can do one on a holiday.” I said firmly. “I will send her right over. Call me when it’s done.” So the tech did it.

Where medicaid goes, medicare follows and then the insurance companies will too. Next, I predict that we will have to fax every note to the appropriate company every single visit, and to the secondary insurance too. And then they will install a video camera in each office and videotape every clinic visit…. and I will either be a physician in another country or be doing something else….

 

What, you say, does the shack have to do with this? I can always go live there, off the grid, if I can’t stand the paperwork and hoops I have to jump through. It is a play house at my family’s land on a lake in Ontario, built in the 1970s. Friends and I put a new roof on this year: their 6 year old was delighted. It would be frightfully cold in the winter and anyhow, I can only stand straight in the middle….

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Go on

I must go on without you
the Beloved opens the path before me
let the past fall behind, the clear parts
and the murky, we alter each memory when we
pull the file in our brain and refile it,
I have duty you see, though I will miss you
terribly and keep inviting you along
as our paths diverge by millimeters
I wonder if you mind perhaps you are relieved
or perhaps you refuse to feel whether you mind
or not, we walk in parallel for now and can still
touch fingertips across the gap, more than
fingertips actually, but not for much longer.
I am still small compared to you yet when I said
to the Beloved that I don’t see how to
carry all of this, my back was infinitely broad and strong
for a period, as if a dream. Kiss me and leave, then,
if you must and I will love you always.

The picture is of early morning fog clearing 1/10/16.

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Armour Suit IV: Walk like a toddler

At each massage, one every two weeks, I have locked my hips back up in the Armour suit. This is really annoying.

My massage person says he wants to be able to lie face down like a baby: head, arms and legs all lifted and playing. That is core strength. Babies can do that… why can’t we? He says that when he does play therapy with kids, by a certain age they lose that. He picks them up and flies them around lying on his arms: by age 4 or 5, they fold up. They have lost touch with that core.

I think about that.

During a massage a few months ago he pokes my lower belly. “Tilt your hips using your abdominal muscles.” Feels weird, but I do. “You aren’t engaging your core.” I find it really annoying to have to relearn how to walk.

Engaging my core. Little children who have just learned to walk do lead with their bellies. And they can still lie on the floor on their bellies, all limbs up.

I am trying to picture an adult who walks with their belly. Who? The Buddha’s belly comes to mind. But I can’t see him walking. Who? Toshiro Mifune: the old samurai movies. He and the others walk like small children: from their core, from their bellies.

I try it for two weeks. I flatten the arch of my lower back by using my abdominal muscles, not my gluteus maximus. I walk with my feet apart a bit, my belly leading. I am trying not to walk with my toes gripping the ground. I walk with toes up. He says I have walked with my toes gripping the ground for years, and that is the only place that I have early arthritis.

It feels a bit silly to walk like a samurai. When I do it right, I can feel that engaged core and my legs and hips feel looser. It is not elegant, not a catwalk uptight shake your ass walk. It is more of a loose free walk, like a toddler, like a buddha. I don’t care. I have to concentrate to keep my abdominal muscles flattening the arch of my back, and so I walk slower.

After two weeks I am back: it’s worked. Partially. My hips are LESS locked. The metatarsal phalangeal joints, the big toes, are less sore then they’ve been for years. And I can feel that abdominal core.

Skiing I try to do the same thing. Engage the abdomen and keep it engaged, and ski with my toes up. I ski slowly and with great swooping turns, letting the skis do the work. Rentals. They give me 158s the first day, I talk them into 165s the second day and then I am on 172s. Finally feels stable. I am getting used to that core feeling. I quit when I get too tired, going in before my kids.

Walk like a toddler, walk like a samurai, walk with core engaged.

First published on everything2.com January 7, 2016. I needed the right picture: this is my sister and me about a month before she died of breast cancer. I miss her so.

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Wean yourself

SoFarSoStu has tagged me for the three days, three quotations and tag three other people. This is day three, only I am a day late.

β€œThe rules are to post 3 quotes over 3 days and nominate 3 bloggers each time to carry on with the challenge.”

Today I choose Rumi’s phrase “Wean yourself” and post his poem. This is one of my two favorite Rumi poems.

Wean yourself
Little by little, wean yourself.
This is the gist of what I have to say.
From an embryo, whose nourishment comes in the blood,
move to an infant drinking milk,
to a child on solid food,
to a searcher after wisdom,
to a hunter of more invisible game.

Think how it is to have a conversation with an embryo.
You might say ‘The world outside is vast and intricate.
There are wheatfields and mountain passes,
and orchards in bloom.

At night there are millions of galaxies, and in sunlight
the beauty of friends dancing at a wedding.’

You ask the embryo why he, or she, stays cooped up
in the dark with eyes closed.

Listen to the answer.

There is no ‘other world’
I only know what I have experienced.
You must be hallucinating.

_____________

I love this poem. To me it’s about our human development and I love that we go from a searcher after wisdom to a hunter of more invisible game. Have you ever had the feeling that you have figured some part of your life out, that aha! moment? Smooth sailing now, you think…. only to find out that new challenges present.

I use this poem in clinic. When I am talking to a new patient I have to find out where they are, what some of their medical beliefs are, what their level of education is, what their prior experience with allopathic medicine is, do they see a naturopath, are they taking ANY pills? Prescription, over the counter, alternative, herbal, homemade? I read Rumi’s poem as a discussion about our levels of development: we come out of the dark to be an embryo. Where do we go from there? I have to understand at least some of my patient’s background in order to communicate with them: I have to meet them halfway. Sometimes I fail. Sometimes my doctors fail…. we experienced that when my mother was in hospice. We were not given instructions for how to take care of her nasogastric tube at home…. and it got blocked. I think that the inpatient nurses made assumptions and the hospice nurses may have too… or just didn’t know.

This poem also relates to how my thoughts about healing and health keep evolving. Currently I keep reading on the internet and hearing from patients that they want a stronger immune system. There are all sorts of “immune system boosters” being sold. I think this is interesting and I think it is a wrong approach. Why?

I have gotten seriously ill four times. Each was triggered by severe stress in my life: mononucleosis at age 19, influenza in 2003, systemic strep A in 2012 and systemic strep A in 2014. So… do I think that my immune system needs boosting? No. When I got symptoms in 2014, my thought was “I am so stupid.” My father had died in 2013. His will confused me, the house was full of his things, my mother’s things, my sister’s things, my grandparent’s things, all dead. I would work in clinic and then go out there and try to get things done and mostly sit and cry. I did deal with the estate, but what is wrong with this picture?

I ignored what I would tell a patient to do…. I did not take time off to rest and to grieve and to take care of myself. Rather than a failing immune system, I pictured my immune system marshaling troops. “She won’t rest. We are going to have to take her down AGAIN. Won’t she ever learn to listen to her body? When will she learn to REST? Let’s see, who doΒ  we have to knock her down…. ah, strep A! Great! Here, the door is open, take her out.”

And boy howdy, did it. I was out for ten months and ten months later am still on half time work. And I could have kicked myself! How stupid I am! If there is a major emotional loss in your life, cut back and rest and take time to let yourself heal!

So when people say, “I need an immune booster,” I wonder. I wonder what is happening in their lives, what their level of stress is, are they taking care of themselves. I worry that our culture thinks that we just need the right combination of supplements and then we can keep going and drive our bodies into the ground, instead of stopping and saying: “Oh. I am really cumulatively tired. I really need to rest, and sit at the beach and stare at the waves, or lie on the couch and read a silly novel, or just have a cup of tea and do nothing.” I don’t really like pills. I think that pills are often a band aid on a deeper wound than we admit. If I had rested, I would not have needed high dose penicillin: though I am deeply grateful to have another try at healing and health.

And three people to tag to do the three days of quotations if they so choose… everyone may be too busy at this busy time of year:

hargunwai

mindlovemisery

ohmyglai

The pink edged cloud looks like a giant paramecium or other bacteria, up in the sky….

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Burning daylight

SoFarSoStu has tagged me for the three days, three quotations and tag three other people. This is day two.

β€œThe rules are to post 3 quotes over 3 days and nominate 3 bloggers each time to carry on with the challenge.”

I learned this phrase from my friend Gary E. He and my then husband would go on week long bike tours. They often stayed in graveyards in small towns because there was a water source. They’d have to leave early because either someone would get annoyed or else the sprinklers would come on.

My husband said that as soon as it was light, Gary would say, “Burning daylight.” and they’d have to get up and ride.

I rode a four day tour with them twice, down the C & O Canal. The Chesapeake and Ohio Canal runs from West Virginia into Georgetown, MD, 185 miles. If you start in West Virginia, you are riding along the canal very gently downhill all the way….

But “Burning Daylight” is older that that. Jack London’s most popular book in his lifetime, published in 1910, is Burning Daylight. It is about the Yukon Gold Rush. I haven’t read it…. yet. Now I need to ask Gary E. where he got the phrase. Films based on the book were made inΒ  1914, 1920, 1928, and 2010. I’ve found the 2010 one… but I would like to read the book first.

And tagging three noders to consider sharing quotations for three days:

Wy of WysJoyful

plato’s groove

cowboy’s girlfriend

Thanks to SoFarSoStu for the tag!

….I am burning night at the moment, up before the sun…..

I took the photo early in the morning at the ski area last week.