Tag Archives: death

by

Painting Angels II

Painting Angels II

After my mother died, I wrote a poem called Painting Angels. It was about my kids’ comments about her death, but also about her being an artist. I wondered whether she was painting the sky or sunsets or clouds. She loved watercolors.

I was driving to the Boiler Room yesterday and came to the hill going down to Water Street and the sunrise was glorious. The leading edge of the front caught fire and there were yellow and orange and pink streaks up into the clouds.

I think my mother and my sister helped paint that sky. I stopped and took photos with my phone until I got too cold and the sun was up.

Thank you, mom. It was a beautiful show in the sky. I lost my mother in 2000, my only sister in 2012 and my father in 2013. I feel that the show has been blessed, and that getting my mother’s artwork out of storage fourteen years after her death and showing it is the right thing to do.

by

Painting Angels

You were an artist
You are an artist
You said that you’d have to live to 120 to finish all your projects
And died at 61
I keep wondering
what the art supplies are like
and if you work on sunsets
or mountains
or lakes

Trey, 9
made a clay fish last summer that I admire.
He said grumpily “It’s too bad Grandma Helen died before I could do clay with her.”
He tells me he’s ready to make raku pots for fire in your ashes as you wished
I ask what he’d make
He considers and says, “What was Grandma Helen’s favorite food?”
I can’t think and say that she liked lots of foods
At the same time wondering squeamishly if maybe
he should make a vase and then being surprised
that I am squeamish and thinking of blood and wine,
too, I wonder if my dad would know. “Maybe guacamole.”
I need to find a potter to apprentice him to.

Camille, 4.
asks how old Grandma Helen was when she died.
I explain that she died at 61 but her mother died at 92.
Camille asks how old I am.
40.
When are you going to die?
I say I don’t know, none of us do, but I hope it’s more towards 90.

Camille studies me and is satisfied for now.
She goes off.
I think of you.

I perpetuate
the Christmas cards you did with us
upon my children
They each draw a card.
We photocopy them and hand paint with watercolors.
Camille wants to draw an angel
and says she can’t.
I draw a simple angel
and have her trace it.
She has your fierce concentration
bent over tracing through the thick paper
She wants it right.
The angel is transformed.

My kids resist the painting after a few cards as I did too.
Each time I paint the angel
to send to someone I love
I think of Camille
and you
and genes
and Heaven
I see you everywhere

published in Mama Stew: An Anthology: Reflections and Observations on Mothering, edited by Elisabeth Rotchford Haight and Sylvia Platt c. 2002

written January 19, 2002

by

Opiate overuse: a change in diagnostic criteria

In the DSM IV, that is, the Diagnostic and Statistical Manual of Mental Disorders, opioid dependence disorder and opioid addiction disorder are separate. Everyone on a chronic pain medicine for a length of time was expected to be dependent, but not addicted. Addiction was considered rare and was thought to be mostly people who abused opiates. Who took them for pleasure. Oxycontin, heroin, vicodon. Those bad people who were partying. Got what they deserved, didn’t they?

That has changed. My feeling was that it’s been a long time coming, but no one asked me.

In the DSM V, opioid dependence and opioid addiction have been combined into “Opioid Use Disorder”. They are no longer considered separate. They are a spectrum. Anyone who is on chronic opioids is on that spectrum. This is a big change. It has not really penetrated the doctors’ consciousness, much less the patients.

It is quite simple to score. There are 11 criteria. They are yes and no questions. Score and add up. The patients are scored mild, moderate or severe.

Here are the criteria:

Opioid Use Disorder requires meeting 2 or more criteria; increasing severity of use disorder with increasing number of criteria met.

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

2. Recurrent substance use in situations in which it is physically hazardous.

3. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

4. Tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxication of desired effect.
(b) markedly diminished effect with continued use of the same amount of the substance.

5. Withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome or
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

6. The substance is often taken in larger amounts or over a longer period of time than intended.

7. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

8. A great deal of time is spent in activities necessary to obtain the substance, use of the substance or recover from its effects.

9. Important social, occupational, or recreational activities are given up or reduced because of substance use.

10. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

11. Craving or a strong desire to use opioids.

Mild substance use disorder is yes to 2-3 of these.

My chronic pain patients ask, “Why do you treat me like a drug addict?”

The answer now is, “Because you are on a chronic opiate.”

I am starting to use the criteria in clinic. When I get a new chronic pain patient, I give them the list. I let them tell me.

It is hard because they often recognize 3 or 4 or 5 or more things on the list. They say, “So this is saying I’m addicted.”

“I’m afraid so.”

They grieve.

I am posting this because people are dying. The number of people dying from prescription medicine overdoses taken correctly has outstripped illegal drug use deaths, approximately 27,000 unintentional overdose deaths in 2007.

Here: CDC Grand Grand Rounds: Prescription Drug Overdoses – a U. S. Epidemic.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

The CDC article says: “The two main populations in the United States at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids, and the roughly 5 million persons who report nonmedical use (i.e., use without a prescription or medical need), in the past month.”That is “approximately” 14 million people.

Please tell your friends and those you love about this. Thank you.

first published on everything2 on June 4, 2014.

by

Cost comparison of brain MRI

I called Advanced Medical Imaging (AMI) in May 2014 to get a prior authorization for a brain MRI with and without contrast.

This is for a woman under 65 who is having short term memory problems. We are looking for treatable causes of short term memory loss. The blood work is negative. Next is the MRI.

Her MRI is already scheduled at the local hospital where I worked for nine years. It is the only hospital because we are a small county.

The AMI representative suggested that the patient get the MRI in Everett.

“The cost there is $917.00. It would be cheaper. It is only 29 miles away.”

“Yes, but Everett is across the sound. She’d have to drive around or take a ferry. What is the cost in Bremerton?” I asked. “At the radiology providers there?”

“The cost there is $967.00.”

“And where she is scheduled?” My local hospital has a “Rural Hospital” designation. Medicare will pay them more than other hospitals.

“$4585.00.”

I squeaked. “For the same MRI?”

“Yes.”

“Um. You should tell the patient.” Except that, is the patient willing to drive to Bremerton? And is the cost to the patient the same? And do they care?

“Do you want the prior authorization for that site.”

“Can it be changed if I talk to the patient?”

“Yes, she can call us.”

The prior authorizations are now site specific. That is, I’m getting approval for the MRI at a specific place. I have no idea why.* Seems stupid. Seems like just another hoop to remember to jump through and if we get it wrong the insurance can say, “Oh, ha, ha, ha, we don’t have to pay for that. You do.” Chalk up some more profit for the investors. Mission accomplished, money made.

I called the woman and explained. She was willing to go to Bremerton and said that she would call AMI. I asked her to call us back if she had any trouble.

The cost really matters to my medicare patients and any patient that has to pay a percentage of the cost. If they only have medicare part B, with no secondary, they pay 20% of the bill. 20% of 4500.00 is a lot more than 20% of $900. But some of my frailest most elderly most confused don’t really have a choice. Going 29 miles might as well be going to the moon.

And this is a woman with memory loss, remember? She wrote down the instructions and repeated them back to me three times.

Every phone call to insurance is like this, and makes me wonder about our culture.

* Actually, the authorizations are site specific because some places are “out of network” and the insurance won’t cover anything done there. Though I think the whole point of health insurance in the US is to try to remove money from people and avoid paying for care.

This was first posted at everything2 on Friday May 9, 2014. The woman died last month.

by

sometimes the hummingbird

sometimes the hummingbird

Boa cat
meows
the meow that means she’s caught something
and wants to show me

and I go to look
it is a hummingbird
probably immature
dead

I pat her and praise her
Good Boa
I see what you caught

She taps the hummingbird
around the room a few times
but it is dead

so she eats it

and I’m crying

sometimes the hummingbird
gets eaten

and that is ok

by

Obese smoking couch potato

I went on the Mad as Hell Doctor’s tour for a week. I went from Seattle to Denver with stops for town halls one to three times a day. We talked about single payer health insurance, HR 676.

One question or objection to a single payer system was: Why should my money go to pay for some obese person who drinks and smokes, doesn’t exercise and doesn’t eat right?

Three answers to start with:

1. You already pay for them.

2. Put out the fire.

3. People want to change.

First: You already pay for them. As a society, we have agreed that people who show up in an emergency room get care. Suppose we have a 53 year old man, laid off, lost his insurance, not exercising, not eating right, smokes, drinks some and he starts having chest pain. Suppose that he lives in my small town.

He calls an ambulance. They take him to our rural emergency room. Oh, yes, he is having a heart attack, so they call a helicopter to life flight him from small town hospital to a big one in Seattle. This alone costs somewhere between $7000 and $12000. Now, do you know how many clinic visit he could have had for $7000? To see me, a lowly rural specialist in Family Practice where I would have looked at his blood pressure and nagged, that is, encouraged him to stop smoking. We would have talked about alcohol and depression. And who is paying for the helicopter meanwhile? All of us. The hospital has to pass on the costs of the uninsured to the rest of the community, the government is paying us extra, with a rural hospital designation. 60% of health care dollars already flow through the government. One estimate of the money freed from administrative costs by changing to a single payer system is $500 billion.

Taking care of people only when they have their big heart attack is ridiculously expensive. It is a bit like driving a car and never ever doing maintenance until suddenly it dies on the highway. No oil, tires flat, transmission shot and ran into a tree in the rain because the windshield wiper fluid had been gone for a while. I get to take care of Uncle Alfred. He is 80 and has not seen a doctor for 30 years and is now in the hospital. “But he’s been fine,” says the family. Nope. He has had high blood pressure for years, that has led to heart failure, he has moderate kidney failure, his lungs are shot from smoking, turns out he developed diabetes sometime in the last 30 years and he’s going blind. Can’t hear much either. We have a minor celebration in the ICU because he doesn’t drink, so his liver actually works. He goes home on 8 new medicines.

Secondly: Put out the fire. When someone’s house is burning down, as a society we do not say, well, she didn’t store her paint thinner right or trim her topiary enough and she has too many newspapers stacked up. We go put out the fire. Putting out the fire helps us as a society: it keeps the fire from spreading to other houses. It saves lives and is compassionate. We think firemen and women are heros and heroines. And they are.

In the past, a homeowner would have to pay for fire service and would have a sign on their home. If the house was on fire and a different company was going by, that company wouldn’t put out the fire. We have the equivalent with health insurance right now. It would be much more efficient and less costly to have a single payer. Medicare has a 3% overhead: it is a public fund paying private doctors and hospitals. The VA is a socialized system, with the hospitals owned by the government and the medical personnel paid by them.

When someone asks why they should help someone else, I also know that they haven’t been hit yet. They have not gotten rheumatoid arthritis at age 32 or had another driver run in to them and broken bones or had another unexpected surprise illness or injury that happened in spite of the fact that they don’t smoke, don’t drink, eat right and exercise. Everyone has a health challenge at sometime in their life.

Third: people want to get better. Really. In clinic I do not see anyone who doesn’t hope a little that their life could change, that they could lose weight, stop smoking. True, there are some drinkers who are in denial, but I will never forget taking the time to tell a patient why he would die of liver failure if he didn’t stop drinking. He came back 6 weeks later sober. I said, “You are sober!” (We don’t see that response very frequently.) He looked at me in surprise: “You said I’d die if I didn’t stop.” He never drank again. It made it really hard to be totally cynical about alcohol and I can’t do it. People change and there is hope for change. I feel completely blessed to support change in clinic and watch people do it. They are amazing. But they need support and they need someone to listen and they need a place to take their fears and their confusion. Primary care is, in a sense, a job of nagging. But it is also a job of celebration because people do get better.

We are already paying, in an expensive, inefficient and dysfunctional way. It saves money to put out the fire. People want to get better. Winston Churchill said, “Americans always do the right thing after they have exhausted all other possibilities.” It is time to do the right thing. Single payer. The current bill is HR676. We can and we will.