My friend is still on the road, but moving closer to the end. Referral to hospice, now, though nothing is imminent. She is not home yet, though we hope to get her there. Yesterday another friend and I took her to see her cat. The cat is being cared for and is more social with everyone.
For the Ragtag Daily Prompt: end of the road.
Two skills needed in primary care are tenacity and listening. That is a combination that can make a diagnosis. Here is an example.
In residency, many years ago, I have a patient with developmental delay. He lives in a group home. He can’t talk though makes some noises. The group home staff bring him to me. His head is misshapen because his mother had measles in her pregnancy.
The staff says, “We think his head hurts. He just isn’t behaving right.”
“Did he fall?”
“We don’t think so.”
“Fever? Nasal congestion? Cough?”
“No.”
“How long?”
“Over the last week.”
I do an exam. I really can’t see his tympanic membranes because of his skull shape.
“Maybe he has an ear infection. I can’t see. We’ll try antibiotics, but if he is not improving, bring him back. In five days.”
They bring him back. “He’s no better.”
I get on the phone. I need a CT scan of his head and the group home say he won’t stay still. I need anesthesia to sedate him for the CT scan. It takes two tries and quite a bit of phone explaining with both the anesthesia department and the radiology department. Persistence. I am looking for a subdural bleed in his head from a fall, or a sinus infection, or something.
It is done and I get a call. Not from radiology or anesthesia but from the ear, nose and throat surgical resident. He is very excited. “Your patient!”
“Yes,” I say.
“He has a pseudocyst! In his sinuses! He has abnormally large sinuses and this is the biggest pseudocyst anyone here has ever seen!”
“Um, ok.” Honestly, I’ve never heard of a pseudocyst. It turns out to be packed nasal drainage in the sinus. Bad ones can erode through bone into the brain. Certainly that seems like the cause of the headache!
“We are taking him to surgery!”
Residency can be pretty weird, when someone gets really excited about a rare disease or interesting trauma case or whatever. I found that I was entirely happy just doing health maintenance exams and encouraging people to quit smoking and exercise and drink less. However, I was also good at finding weird things.
The ear, nose and throat surgeons in training were very happy about the surgery. The group home staff were happy too. “He’s back to his old self. Thank you!”
It took tenacity to set up the head CT. It’s important to listen to the families and caregivers too, because they know the person better than I do. They were right: his head hurt. And we found out why and were able to treat it.
For the Ragtag Daily Prompt: tenacity.
Water is tenacious too, wearing down stone and wood and glass.
The stockings are ready!
This is from last year. I forgot to bring my stocking this year. I will have to use a sock! Well, Santa will surely understand.
My ex says happy chanakwanschristmasfeliznavidad. All one word. And love, joy and peace to you and yours too.
For the Ragtag Daily Prompt: holiday.
I am writing this on Christmas morning.
The good news is this: National Guard Empties Bedpans and Clips Toenails at Nursing Homes. “In Minnesota, an ambitious initiative is training hundreds of Guard members to become certified nursing assistants and relieve burned-out nursing home workers.” (1) Well, hooray, the National Guard is called out to help, because the nursing homes are out of staff and we aren’t supposed to abuse our elderly. I think this is AMAZING. And the National Guard may learn some things about work and the elderly too. Hoorah and Hooray!
The bad news is a snippet from New York State: Omicron is milder, BUT the exception may be children. (2) Child cases of Covid-19 are going up really fast and hospital admissions of children. ICU work is hard hard hard, but child and infant ICU is even harder. Blessings on the nurses who do this and the physicians too. When I did my pediatrics rotation way back in Richmond, VA, in a tertiary care hospital, I had children who were dying: one with a brain tumor, one with liver cancer, one with Wilm’s disease. Hard work. I chose Family Practice. I have still had pediatric patients die, including an 18 month old where I had taken care of mother through the pregnancy, but not terribly many. Even less in the last ten years since my average patient was about age 70. All of my kids in the last ten years were complicated: one with Down’s, another a leukemia survivor, others. Children can be very medically complicated. I had two adults who had survived infant heart surgery as well. They were set up with UW’s Adults who had Childhood Heart Surgery Clinic, though that is not the correct name. I am pretty happy to have that sort of back up only two hours away. They both had pretty awesome heart murmurs and that midline chest zipper scar. Ouch.
So, why post this on Christmas? If the cases are rising in children, maybe that will inspire some folks to get vaccinated or at least not yell at family who refuse to bring small children to an unvaccinated Christmas gathering. Judging by the posts on the doctor mom facebook group, there is quite a bit of family yelling going on. Stand down, folks, and respect other peoples’ boundaries.
The problem is, if enough children are sick, we run out of beds. And staff. “As of Thursday, there were 1,987 confirmed or suspected pediatric covid-19 patients hospitalized nationally, a 31 percent jump in 10 days, according to a Washington Post analysis.” (3)
Blessings.
2. https://www.nytimes.com/2021/11/23/us/covid-cases-children.html
3. https://www.washingtonpost.com/health/2021/12/24/omicron-children-hospitalizations-us/
Care for your family and friends and community. Mask up and do the best you can not to get nor give Covid-19 this season. The winter is dark but the sun will start returning to us soon. Like the seeds in the ground and the trees with no leaves, we can get through this dark season caring for each other.
I posted this in November, 2015. I am reposting it.
_________________
Why care for addicts?
Children. If we do addiction medicine and help and treat addicts, we are helping children and their parents and our elderly patients’ children. We are helping families, and that is why I chose Family Practice as my specialty.
Stop thinking of addiction as the evil person who chooses to buy drugs instead of paying their bills. Instead, think of it as a disease where the drug takes over. Essentially, we have trouble with addicts because they lie about using drugs. But I think of it as the drug takes over: when the addict is out of control, the drug has control. The drug is not just lying to the doctor, the spouse, the parents, the family, the police: the drug is lying to the patient too.
The drug says: just a little. You feel so sick. You will feel so much better. Just a tiny bit and you can stop then. No one will know. You are smart. You can do it. You have control. You can just use a tiny bit, just today and then you can stop. They say they are helping you, but they aren’t. Look how horrible you feel! And you need to get the shopping done and you can’t because you are so sick…. just a little. I won’t hurt you. I am your best friend.
I think of drug and alcohol addiction as a loss of boundaries and a loss of control. I treat opiate overuse patients and I explain: you are here to be treated because you have lost your boundaries with this drug. Therefore it is my job to help you rebuild those boundaries. We both know that if the drug takes control, it will lie. So I have to do urine drug tests and hold you to your appointments and refuse to alter MY boundaries to help keep you safe. If the drug is taking over, I will have you come for more frequent visits. You have to keep your part of the contract: going to AA, to NA, to your treatment group, giving urine specimens. These things rebuild your internal boundaries. Meanwhile you and I and drug treatment are the external boundaries. If that fails, I will offer to help you go to inpatient treatment. Some people refuse and go back to the drug. I feel sad but I hope that they will have another chance. Some people die from the drug and are lost.
Addiction is a family illness. The loved one is controlled by the drug and lies. The family WANTS to believe their loved one and often the family “enables” by helping the loved one cover up the illness. Telling the boss that the loved one is sick, procuring them alcohol or giving them their pills, telling the children and the grandparents that everything is ok. Everything is NOT ok and the children are frightened. One parent behaves horribly when they are high or drunk and the other parent is anxious, distracted, stressed and denies the problem. Or BOTH are using and imagine if you are a child in that. Terror and confusion.
Children from addiction homes are more likely to be addicts themselves or marry addicts. They have grown up in confusing lonely dysfunction and exactly how are they supposed to learn to act “normally” or to heal themselves? The parents may have covered well enough that the community tells them how wonderful their father was or how charming their mother was at the funeral. What does the adult child say to that, if they have memories of terror and horror? The children learn to numb the feelings in order to survive the household and they learn to keep their mouths shut: it’s safer. It is very hard to unlearn as an adult.
I have people with opiate overuse syndrome who come to see me with their children. I have drawings by children that have a doctor and a nurse and the words “heroes” underneath and “thank you”. I have had a young pregnant patient thank me for doing a urine drug screen as routine early in pregnancy. “My friend used meth the whole pregnancy and they never checked,” she said, “Now her baby is messed up.”
Addiction medicine is complicated because we think people should tell the truth. But it is a disease precisely because it’s the loss of control and loss of boundaries that cause the lying. We should be angry at the drug, not the person: love the person and help them change their behavior. We need to stop stigmatizing and demeaning addiction and help people. For them, for their families, for their children and for ourselves.
I am posting this for today’s Ragtag Daily Prompt: action.
Well, for every action there is an equal and opposite reaction, right? Which could be a nap. This is taken with my phone zoomed from an upstairs window, right in my back yard. Voyeur, yep, that’s me, spying on my Giant Long Earred Yard Rats, also sometimes called Deer.
All of my 911 memories are still swirling around. I think everyone is exhausted and grieving. Please take care of yourselves today and I hope you have a safe place to take a nap, like my Giant Yard Rats.
My daughter is home and we went on a beach walk yesterday! The stupid oxygen keeps me from going fast. She went for a bike ride afterwards. Hooray!
Yesterday evening she brought up social distancing and how careful she should be. She has about 5 friends who are home that she is going to walk with. I am still wearing a mask over my oxygen tubing most places. She will unmask if they are vaccinated and they don’t have a cold or anything else. Even a cold would make me worse at this point. It makes me grumpy to be vulnerable, but I appreciate the discussion.
No snow now, but the Anna’s hummingbirds were guarding the feeder most of the time when it was cold, especially when I would thaw it. One especially cold hungry day, it dive bombed me when I went to wrap a warm towel around the feeder to warm it up. Fierce little birds!
But it also did the behavior pictured. I think it’s beak cleaning, but it sure looks like sharpening. Just like sharpening a knife.
Prayers for the flooded and for rescue and care. Sending love. And money.
For the Daily Prompt: critical. It is critical to find everyone who is still lost, flooded, ill.
BLIND WILDERNESS
in front of the garden gate - JezzieG
Discover and re-discover Mexico’s cuisine, culture and history through the recipes, backyard stories and other interesting findings of an expatriate in Canada
Or not, depending on my mood
All those moments will be lost in time, like tears in rain!
An onion has many layers. So have I!
Exploring the great outdoors one step at a time
Some of the creative paths that escaped from my brain!
Books, reading and more ... with an Australian focus ... written on Ngunnawal Country
Engaging in some lyrical athletics whilst painting pictures with words and pounding the pavement. I run; blog; write poetry; chase after my kids & drink coffee.
spirituality / art / ethics
Coast-to-coast US bike tour
Generative AI
Climbing, Outdoors, Life!
imperfect pictures
Refugees welcome - Flüchtlinge willkommen I am teaching German to refugees. Ich unterrichte geflüchtete Menschen in der deutschen Sprache. I am writing this blog in English and German because my friends speak English and German. Ich schreibe auf Deutsch und Englisch, weil meine Freunde Deutsch und Englisch sprechen.
En fotoblogg
Books by author Diana Coombes
NEW FLOWERY JOURNEYS
in search of a better us
Personal Blog
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𝖠𝗇𝗈𝗍𝗁𝖾𝗋 𝖶𝗈𝗋𝖽𝖯𝗋𝖾𝗌𝗌.𝖼𝗈𝗆 𝗌𝗂𝗍𝖾.
Taking the camera for a walk!!!
From the Existential to the Mundane - From Poetry to Prose
1 Man and His Bloody Dog
Homepage Engaging the World, Hearing the World and speaking for the World.
Anne M Bray's art blog, and then some.
KO Rural Mad As Hell Blog 
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