Tag Archives: confusion

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On guard

My nurse’s breath catches. “Oh, no,” she says.

I am new here. Less than a year. “What?” I say.

“We have Janna Birchfield on the schedule.”

“Who is Janna Birchfield?”

Tonna leans back in her chair at the nurse’s station, a high set desk that runs behind the front office. We have new glass barriers along it to make it more hipaa compliant. It is also more claustrophobic. She throws her pen down. “She’s one of the most hostile people here. She’s known for throwing a brick through her second doctor’s plate glass window.”

“Ah,” I say.

“She was Dr. M’s patient but apparently she and Dr. K got in a screaming fight in the hallway. She is banned from that clinic. So we are the last clinic in town.”

My nurse knows the local stories and she has seen a lot. She doesn’t have a lot of unconscious monsters. Yeah, there is some impatience and some anger there, but she’s pretty good. No real fear, nothing cringing at her feet.

“Hmm. Let me talk to Marnie.” Marnie is our office manager.

Marnie and I talk. I read the last notes from Dr. M and an account of the screaming fight with Dr. K. I call Dr. K. I don’t know of anything that scares her and she is tough. I rather enjoy envisioning her yelling back at this patient.

The day arrives and Mrs. Birchfield is put in a room. Vitals are done. I go in.

Janna Birchfield is big. She weighs about twice what I do, and it’s muscle rather than fat. She looks solid. Not like a body builder, just strong. She tops me by nearly a foot. She looks sullen and unfriendly.

And I am looking at her monsters. Three are guarding a fourth, at her feet. Fear is there, anger is the biggest and posturing, like a body builder, in front. The third is morphing back and fourth: envy and hostility. The fourth is in a stroller, guarded by the other three. Asleep? Unconscious? Well, yes, duh, but it’s not often that a monster is so undeveloped that it is still an infant. Not good.

“Hi, Miz Birchfield. I am Dr. Gen.” I hold out my hand, moving slowly and smoothly. Her monsters alert, fear flinching and anger ready to punch. I stand with my hand out. She eventually touches it, glaring.

“Hi,” sullen.

“We need to talk about the clinic rules first.” I say calmly. Anger puffs up and her shoulders rise as the monster swells and takes control, her elbows rising and hands are fists. Her eyes don’t turn red, but nearly. “I have heard about your argument with Dr. K.”

Furious voice, “She screamed at me. She’s a horrible doctor! She got me thrown out!”

I am smooth and calm, “I am not going to discuss Dr. K,” I say. Honestly, it’s even more fun to think of Dr. K taking this on and not budging an inch. Dr. K is my size, small. “In this clinic, I need you to understand that you are not allowed to yell at anyone at the front desk, in the hallways or on the phone.” Anger flees immediately, small again and she looks confused. “You may not yell at the staff, at the other patients, or at anyone on the clinic property.”

“Why would I agree to that?” she says. She is mostly confused because I am not scared or angry. I am not behaving the way she expects, the way most people behave around her.

“If you are upset, the only people you can yell at are me or the office manager and you need an appointment.”

“They are rude to me!” Basically she means everyone. “You can’t make me do that!”

“Take it or leave it.” I say. “You need to agree and keep the agreement, or we will discharge you immediately. If you say no, leave now, and I won’t charge for the visit.”

Her monsters are confused. Anger has shrunk back down and they are conferring, heads together. Confusion has shown up as well, morphing though different colors and stripes, stars and paisleys. She stares at me, frozen hostility. I just wait, sitting in front of my laptop, serene. This is going well. She isn’t yelling and she hasn’t left.

“What if they are mean?” she says.

“You will make an appointment with me or the office manager, and we will help you.”

“Ok,” she says. The monsters are still surrounding the carriage, but really, now confusion is in charge. We work through the rest of the visit, as I get to know her a little. She has had a hard, hard life.

I let the front office and the nurses know the rules. The office manager and I let them know that this is a contract with the patient and she has agreed. They feel protected. They feel protected enough that they are nice to her. She behaves and starts, infinitesimally, to relax. She is still angry and hostile in the exam room but it’s not directed at me. It is directed at the entire world, the rest of the world outside the clinic. I try to help her medically but also let the monsters have their say. The visits start with anger and hostility but tend to subside into confusion. I am not getting at the fear or whatever is in the stroller. It is one of the large old fashioned ones, heavy, navy blue, where an infant can lie flat. Clearly it does not fold up to go in a car or anywhere else convenient. There are no toys hanging from the top or across it, no stuffed animals. Only a form under the blankets, always still.

I may reach that form, or not. I do not know.

For the Ragtag Daily Prompt: paleontology.

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Visit

It is time to visit. It has been long enough and it is time.

He is in a dungeon. I have to go down flight after flight of stairs. It gets colder and damper and there is mold growing on the walls and puddles. Light comes with me.

I can hear him one flight above finding him. He’s having a tantrum and hitting something.

I find the door in the dungeon. It is thick and moldy damp wood with bars in the window and a huge lock. It is also open. My friend is screaming at the ceiling and hitting the ceiling and walls with a yard long heavy pipe. It clangs and I feel a tremor when he hits metal. There is no window, we are too far underground.

I lean on the doorway. “If you go deeper in to the earth, it will be warm and dry.”

He turns with the pipe held like a bat. He is huge and muscular and dressed in rags and very threatening. The room is mostly dark. He sheds a faint light. He glares at me and then lowers the pipe. He shrinks to his child self, like me. About age three.

“You are awfully cute at three.” I say.

He drops the pipe and lets me come hug him. The cell smells truly awful. There is a drain in the floor that appears to be working, sort of. There is a visible liquid level below the drain.

He is still while I hug him and then relaxes. “Ok,” he says. Silence for a minute. “I didn’t really think you’d come back.”

“Friends forever, right? That’s what you said.”

“Yeah, but,” he hesitates. “You were mad.”

My turn to shrug. “Yes. I got over it.”

“Took you long enough.”

My eyebrows go up. “You could have made the first move.” Now he shrugs.

“How about a picnic?” I say. “This is icky. Let’s get out of here.”

He looks at the ceiling. The stone is scratched and chipped. “Yeah. No progress here. Might as well.”

We leave the cell and go up. “Damn stairs.” I say.

“Your lungs are good.” he says.

“Most people’s lungs are pretty good at three.” I say.

“You are pretty cute at three too.”

“Thanks.” I get tired of the stairs and transport us to a meadow in my garden. It is summer and full of wildflowers. It is on a sloped hill with an enormous willow tree. “This is from when I was 7, really.” I say.

“Nice.” he says.

I have a picnic basket and get food out. We don’t really need to eat but it’s fun anyhow. We can taste food, a bit. His keeps turning black on his plate.

“Cut that out.”

A shrug again. “I like bugs now.”

“Did you at three?”

“Naw, but I ate them if I was hungry. Ants are not good. Grasshoppers are better.”

“Are you making any progress at all?”

He leans back on the hill, about as relaxed as he gets. Still hyper alert to everything around us. “No, and I don’t think I will. He’s 69 now. Getting older.”

“Well, he’s expecting to die of a stroke at 80.”

“Yeah, it’s pretty much too late. There is too much to process. And wine and pot do not help.”

“Using more?”

“Yeah.”

“Let’s talk about something more fun. Politics or taxes or something.”

He laughs.

We talk about cabbages and kings. Why the sea is boiling hot and whether pigs have wings. The sun moves like the real sun.

He is starting to fidget.

“Time?” I say.

“Yeah. You know, it’s not fair that they need us even if they won’t listen.”

“Seems like it.”

He glances at me and away. “Yours listens.”

“You’ve seen the results of that.”

He looks down. “Is she happy?”

“Sometimes. Sometimes sad, sometimes lonely, sometimes impatient. You know, all of it.”

He nods. We start packing up and we trek back to the dungeon and the endless stairs. We have gone down two flights when the landscape shifts. A forest, dark and huge trees and overcast. Damp and cool. He is morphing. “Oh!” he says, “Asleep again! And it’s 4 pm. Must be tv. And wine.” There is a small clearing in sight with a shack. It looks run down, no vehicles. My friend has morphed and split. He is a huge bear with red eyes. And an older man who smells of alcohol and reaches into his shirt for a handgun.

“Really?” I say to the man with the gun.

“They are his memories,” growls the bear. “I have to go.”

“Well, the bear isn’t. Goodbye and good luck.” I say, patting a furry leg. “I will come back.” But he is not paying attention any more, he is focused on the shack.

I go home and he goes to try again. Wake up, my friend, wake up.

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For the Ragtag Daily Prompt: confusion.

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Keep it simple

Sometimes I just despair as I read new guidelines. Don’t you? Maybe you are not a physician and don’t try to keep all of this impossible stuff in your head. Mine is full. Tilt.

Diabetes alone: if someone has type II diabetes, there are specific blood pressure guidelines, cholesterol guidelines, we are to do a hgbA1C lab test every six months minimum and more often if they are out of control, and a urine microalbumin/creatinine ratio yearly. If that starts being abnormal we are to start one of two classes of blood pressure medicines even if they have normal blood pressure.

Oh, and don’t forget: a yearly eye test and we are supposed to check their feet at EVERY visit to make sure they are not getting diabetic ulcers.

Got that? And that is just type II diabetes. And there are a whole raft of medicines, about forty right now. Some are weekly shots, some are daily tablets, some are twice a day or with every meal and they all have their own side effects, how fun. Check drug interactions, are their kidneys ok? Is their liver ok? Diabetes increases the risk of heart attack and stroke and don’t forget those feet.

Diabetes is one of the most complicated sets of guidelines, but there are a rather appalling number of guidelines. Maybe we should sic an AI on that job: Mr. Smith has type II diabetes poorly controlled, hypertension, erectile dysfunction, feels a little short of breath and has a bruise on his left shin after tripping yesterday. Please, AI, organize a twenty minute visit to cover as many things as possible efficiently and have the note finished and followup arranged by the end of it. Then it turns out that what Mr. Smith really wants to talk about is his niece who has just overdosed and nearly died from heroin, so everything else goes out the window. Maybe I should see him weekly for the next month.

Do you want to keep it simple and stay out of the doctor’s office and more importantly out of the hospital? If you are 25 and healthy, you don’t much care because old is unimaginable.

But there is a very nice study that looked at just five things regarding health, over 28 years for men and 34 for women: “The researchers looked at NHS and HPFS data on diet, physical activity, body weight, smoking, and alcohol consumption that had been collected from regularly administered, validated questionnaires.”

Here is an article about the study: https://www.health.harvard.edu/blog/healthy-lifestyle-5-keys-to-a-longer-life-2018070514186

Here is the study: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.032047

So let’s break the five things down. Here are the more formal definitions: “Using data from the Nurses’ Health Study (1980–2014; n=78 865) and the Health Professionals Follow-up Study (1986–2014, n=44 354), we defined 5 low-risk lifestyle factors as never smoking, body mass index of 18.5 to 24.9 kg/m2, ≥30 min/d of moderate to vigorous physical activity, moderate alcohol intake, and a high diet quality score (upper 40%), and estimated hazard ratios for the association of total lifestyle score (0–5 scale) with mortality.”

First: never smoking. I would add never vaping and not living in a cave and burning wood and hopefully not living right next to a 12 lane superhighway, all of which are bad for the lungs. Ok, while we are at it, don’t use methamphetamines or heroin or cocaine or krocodil, right? They didn’t even include those in the study.

Second: Body mass index 18.5-25. If you aren’t there, it is diet and exercise that need to change.

Third: Thirty minutes or more per day of moderate to vigorous physical activity. That can be ten minute intervals. Three can have an enormous effect on number two.

Fourth: moderate alcohol intake. Ok, alcohol is bad for the heart, period. So is tobacco. They defined moderate as less than or equal to “5 to 15 g/d for women and 5 to 30 g/d for men”. Let’s do the math: a 12 ounce beer that is 5% has 14gm of alcohol. Here: https://www.niaaa.nih.gov/alcohols-effects-health/overview-alcohol-consumption/what-standard-drink. The 8.9% 16 ounce beer at our local pub has quite a bit more. Here is a website where you can calculate how much alcohol is in a drink: https://www.rethinkingdrinking.niaaa.nih.gov/Tools/Calculators/Cocktail-Calculator.aspx.

Fifth: Diet. There is an overwhelming amount of confusing information on the internet and some of it is not only confusing but wrong. “Diet quality in the NHS, HPFS, and NHANES was assessed with the Alternate Healthy Eating Index score (Methods in the online-only Data Supplement), which is strongly associated with the onset of cardiometabolic disease in the general population.” I have not assessed my own Alternate Healthy Eating Index score. However, there are a couple very straightforward things that help with diet. First: No sweetened drinks. That means that sugary coffee with the syrup should go. I quit drinking mochas when I read that a 12 ounce one has 62 grams of carbohydrate. I would rather have a small dark chocolate. And sodas are just evil and juice not much better. Eat the fruit instead. Second: eat vegetables, every meal. A fruit is not a vegetable and no, potato chips don’t count. I mean a green or yellow or red vegetable. You can saute any vegetable, or any that I can think of. I am not counting grains as a vegetable, so pasta, pizza, potato chips and so forth do not count. Beans do count. Third: the DASH diet recommends only a tablespoon of sweetener per day. That is not very much. You can make that cheesecake slice last a week! A small piece of dark chocolate daily or tablespoon size chunk of that cheesecake.

I had a diabetic patient who would be fine, fine, fine, then out of control. “WHAT are you eating? And drinking?” The first time it was two 16 ounce Mochas a day. Then he was fine for a year and a half. Then labs went haywire again. “What are you drinking?” “Well,” he said, not wanting to admit it, “Ok, I decided to try Caramel Machiattos.” “No, no, no! You can’t do that! You’ll end up on insulin!” “Ok, ok, got it, got it.”

And what is the difference if I try to do those five things, you ask, skeptical. “We estimated that the life expectancy at age 50 years was 29.0 years (95% CI, 28.3–29.8) for women and 25.5 years (95% CI, 24.7–26.2) for men who adopted zero low-risk lifestyle factors. In contrast, for those who adopted all 5 low-risk factors, we projected a life expectancy at age 50 years of 43.1 years (95% CI, 41.3–44.9) for women and 37.6 years (95% CI, 35.8–39.4) for men.The projected life expectancy at age 50 years was on average 14.0 years (95% CI, 11.8–16.2) longer among female Americans with 5 low-risk factors compared with those with zero low-risk factors; for men, the difference was 12.2 years (95% CI, 10.1–14.2).”

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I took the photograph from Marrowstone Island. What does a healthy seal diet look like? I am so lucky to have miles of beach to hike, as long as I watch the tides and don’t mind rain.

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Blessing

Blessing

You have my blessing to travel
Now, then forever.

You have my blessing to travel
With your guitar.

Go, with my blessing, travel.
Or don’t, as you will.

You have my blessing to hunt.
Now, then, forever.

You have my blessing to hunt
With your guns.

Go, with my blessing, hunt
Or don’t, as you will.

You have my blessing to sing.
Now, then, forever.

You have my blessing to sing
With your guitar.

Go, with my blessing, sing.
Or don’t, as you will.

You have my blessing to travel
But not with me.

You have my blessing to hunt
But not with me.

You have my blessing to sing
But not with me.

You have my blessing, not me.
Now, then, forever.

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For the Ragtag Daily Prompt: grief.

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Perspective

This is taken at night from the beach, camera at full zoom. The mountain is Mount Tahoma, also known as Mount Rainier. The object that looks like a gibbet for hanging people is at the end of a dock. It is a small crane.  The perspective makes them look like they are the same size, doesn’t it? But one is very close and the mountain is very much further away.

We have to be careful not to misinterpret what we see when we don’t have enough information or when we are given misinformation. Truth is complicated and there are people who will lie for power and advantage and their own agenda. Consider the source, use more than one source, consider if what you are seeing has been edited, exaggerated, placed out of context or if it’s really just a lie.

For the Daily Post challenge: Conventional Wisdom.

Music: I can’t keep quiet.

 

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Random confuse the engine search

A friend and I are using Facebook to message this am and she says she hates that Facebook is mining for advertising all the time. I said we should do a random confuse the engine search every day. Something silly! I searched enamel zebra hamsters first…. And it’s fun to watch the internet try!

What silly search would you use to confuse the big data mining on the internet? Go wild! Confuse your feed!

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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….