Butterfly Girl Comes to Visit

For the Daily Prompt: carve. I think of skiing, bicycling. And I think of a piece of my heart. I wrote this in the early 2000s.

Butterfly Girl Comes to Visit

She is so beautiful with her wings
multicolored many splendored lights caught and multiplied
as she flutters

I freeze
I am an ogre
Huge and clumsy
I know from past past many times
Not to touch you
My rough fingers have brushed the tiny feathers from your wings
You cry in pain and your flight becomes erratic
My kiss is just as bad
Rough lips
If I move the wind of my passing blows you against a window
You fall stunned

I hold and crush
the box of feelings that can hurt you
Sorrow, anger, fear, dismay
Even fatigue turns my aura red
And scorches your wings

I hate to cause you pain

Fly butterfly girl
My baby needs me, my pager rings
My ogre husband stirs
The effort of holding still plain on his face
I can’t hold still much longer

Butterfly girl
Fly on home

on fire

This is an early morning photograph, downtown, not this year.

It was frightening to fly back from Wisconsin last week and have the plane descend into smoke in Seattle. The smoke from fires in British Columbia and Washington blanketed the city. I am used to descending into cloud, but smoke looks brown and was neither opaque nor transparent. Haze.

I missed the worst air, but the smoke still bothers me. One afternoon my receptionist and I both were having trouble with eye irritation from the bad air. My clinic is in a 1950s building and closing all the windows and doors is hot! No air conditioning.

I am hoping that we make changes to slow and mitigate climate change and global warming: I don’t want the world on fire!

How many summers will it take? My guess is three consecutive summers….

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!

Adverse Childhood Experiences 4: Psychophysiological Illness

I went to the 46th Annual OHSU Primary Care Review, held at the Sentinel Hotel in Portland, Oregon last week.

It was excellent. It was surreal since the Sentinel Hotel started as a 1923 Elks’ Club and the satyr cupid friezes kept distracting me with the marble penises and war chariots during the lecture updating us on urinary incontinence.

Three lectures that I went to talked about Adverse Childhood Experiences.

This is the first conference that I’ve been to that anyone has talked about that study since I heard about it, in about 2005. I have not been to a lot of big conferences over the last few years because I opened my own clinic and money was tight.

Anyhow, the study is creeping into consciousness.

In the mornings, we had the big lectures in a large hall. There were three break out sessions in the afternoon, held in the main meeting, billiard room, club room and library. We all joked about Colonel Mustard and candlesticks.

A gastroenterologist, Dr. David Clarke, gave a two hour session titled “Hidden Stresses and Unexplained Symptoms II”.

Objectives:
1. How to uncover the cause of an illness when diagnostic tests are normal.
2. How to find hidden psychosocial stresses that are responsible for physical symptoms.
3. The process used to achieve successful outcomes in stress-related illness.

He talked about childhood stress. That if someone had a really difficult childhood:
“Surviving a dysfunction home is a heroic act and produces individuals who are:
a. reliable and get things done
b. detail-oriented
c. Perfectionist
d. Hard-working
e. Compassionate”

So what is the down side? “Surviving a dysfunctional home also produces emotional consequences that may lead to :
a. Long-term relationships with partners who treat you poorly.
b. Addictions to nicotine, Alcohol, Drugs, Food, Sex, Gambling, Work, Shopping, Exercise.
c. Quick Temper or being violence prone
d. Anorexia and/or bulimia
e. Mental health problems such as nervous breakdown or suicide attempts
f. Sacrificing your own needs to help others
g. Self-mutilation
h. Learning not to express or feel your emotions.”

Got that? Right. Not everyone, not all the time, but the adverse childhood experiences add up. These reliable individuals may eventually get enough positive feedback to decide that they deserve a relationship that is actually good. They may get angry about their childhood or past bad treatment. “They may have a really hard time expressing that anger because they spent years learning how to suppress emotion and the feelings may be directed at people for whom there is still some caring. When there is enough of this anger present it can cause physical symptoms that can be mild or severe or anywhere in between.”

Let me give two examples from my own practice. I can’t remember their names or the details, so I am making those up: no hipaa violation.

The first was an elderly woman who came in with her husband for stomach pain. We started with a careful history. We tested for helicobacter pylori. We tried ranitidine. We tried omeprazole. We studied her diet and did an ultrasound to rule out gallbladder disease.

At the third visit I was starting to talk about an upper endoscopy. This was more than 15 years ago, back when we did not start with a CT scan. Her husband said, “Doctor, is there anything else it could be?”

I was surprised. “Well, yes. Depression is on the diagnosis list. Sometimes depression can present as stomach pain. Could you be depressed?”

My elderly lady covered her face with her hands, started crying and said, “I try not to be!” while her husband nodded.

We cancelled the endoscopy. I said it really was not something to be ashamed of and we talked about therapy. She did not want talk therapy and we tried paxil. She came back in two weeks, and already she and her husband were brighter and relieved.

Second case: again, stomach pain, this time in a four year old. Mom brought her in.

I did a history and did a gentle exam. The exam was normal. Her stomach was not hurting now. She wouldn’t say anything.

We established that the stomach pain occurred on week days only, not on the weekend. In fact, usually at the after school daycare, not in school.

“Is there a time at the school daycare that she has stomach pain?” Mom was shaking her head when big sister piped up.

“It happens before recess.” Mom and I turned to stare at the six year old.

I said, “What happens at recess?”

“The big kids knock her down,” said big sister, pissed. “I try to stop them, but they are bigger than me. She’s scared. The teachers don’t see.”

“Oh. Thank you for telling us!” Little sister was crying and mom hugged her and big sister. Mom did not need instruction at that point. She called me a few days later. She talked to the daycare, they watched and the four year old was protected. Her stomach stopped hurting.

Dr. Clarke also described a case, where driving through a town would trigger four days of nausea and vomiting that required hospitalization. This had been going on for 15 years. He figured out why that particular town was a trigger: when the patient recognized the why, he was able to go for therapy.

People aren’t lying about these illness, they are not making them up. Doctors have called it somatization, but really it is the body holding the emotions until the person is safe enough to deal with them. Doctors need to learn how to recognize this and help with respect instead of stigmatization and dismissal.

I hope that more doctors learn soon…

Dr. Clarke’s list for further reading is below. I don’t have any of these yet, but they are on my wish list.

They can’t find anything wrong!, by David Clarke, MD. See also www.stressillness.com

Psychophysiologic Disorders Association: www.ppdassociation.org

Caring for Patients, Alan Barbour, MD

Unlearn Your Pain, Howard Schubiner, MD

Pathways to Pain Relief, Frances Anderson PhD and Eric Sherman PhD

Ted talk about ACE scores: http://www.acesconnection.com/blog/nadine-burke-harris-how-childhood-trauma-affects-health-across-a-lifetime-16-min

the problem with angels

the problem with angels

the problem with angels
is that they aren’t grey

nor do they have color

they are black
or white

sort of boring, really

pick one side
good or evil
night or day
male or female

I would rather be fluid

I want to be able to transform

liquid to solid
solid to gas
gas to solid
gas to liquid

flow around things

seep into the earth

always always
return to the sea

keep your wings

project black or white
as you choose
on me

while I flick water at you
and go for a swim

also published on everything2 today

Taking care of Ebola is hard

“We may never know exactly how [transmission] happened, but the bottom line is that the guidelines didn’t work for that hospital,” said Frieden. “Dallas shows that taking care of Ebola is hard.”

From the Huffington Post: http://www.huffingtonpost.com/2014/10/20/ebola-hospitals-us_n_6018372.html

And for me, a lowly rural Family Practice physician, from the American Academy of Family Practice: “The first steps in preparing your office for a possible Ebola case are to make sure you have all referral contact information ready to go and that you educate each staff member on his or her role should a case present.”

There is only me and a receptionist. We don’t have hazmat suits. Actually I’ve been off sick, lung and vocal cord problems, for all of October.

We have masks, gloves, I do have a white coat that I almost never wear.

Also from the AAFP:”Appointment clerks and front-desk personnel taking calls for appointments should inquire about African travel history in patients calling for appointments for fever, headache, weakness, diarrhea, vomiting, muscle aches or bleeding,” said Mahoney. “Anyone with a positive travel history should be contacted by a provider to gather additional history and determine if public health authorities need to be involved before a patient even presents to the physician office.”

http://www.aafp.org/news/health-of-the-public/20141017eboladisprep.html

We are both going to get our influenza shots this week. Please get your influenza shot. There is a lot more influenza around than risk of ebola in the United States, and influenza kills many many people every year. And even if you “never get colds” and “have a strong immune system”, you might get a mild case of influenza and pass it on to someone who then dies of it. If you tell me “I got flu the last time I got the shot”, excuse me, but that is hooey. First of all, it takes two weeks for your immune system to respond to the shot, so if you got symptoms the next day it could be influenza but not from the shot. Maybe from being exposed to someone with influenza at the grocery store or your doctor’s office. Secondly, people say “flu” and often they mean stomach flu. Stomach flu is not influenza. Third, influenza changes all the time, so about 80% of the vaccinated people are protected most years. That’s right: two weeks after my influenza shot, I am about 80% protected. Not 100%.

Why are we getting vaccinated? For one thing, we are health care workers and we get exposed. And for another, the initial symptoms of influenza are the same as the initial symptoms of ebola. Actually the United States is really rather lucky that the ebola case happened before influenza really hit, because they look too much the same initially. Suppose that three of the quarentined people had come down with influenza….. confusion and panic initially.

So please get your influenza vaccine, because you not only help to protect yourself, but protect others and prevent panic.

Blessings!