Tag Archives: heal

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Adverse Childhood Experiences 15: Guidelines

I wrote Adverse Childhood Experiences 14: Hope quite a while ago.

The American Academy of Pediatrics has a guideline that physicians should introduce and screen for Adverse Childhood Experiences. The American Academy of Family Practice is skeptical, here: https://www.aafp.org/pubs/afp/issues/2014/1215/p822.html. Here are two more writeups: https://www.aafp.org/pubs/afp/issues/2020/0701/p55.html and https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/screen_for_aces.html.

It is difficult to screen for ACE scores for the same reason that it is difficult to screen for domestic violence and to talk about end of life plans. These are difficult topics and everyone may be uncomfortable. Besides, what can we DO about it? If growing up in trauma wires someone’s brain differently, what do we do?

I don’t frame it as the person being “damaged”. Instead, I bring up the ACE score study and say that first I congratulate people for surviving their childhood. Good job! Congratulations! You have reached adulthood! Now what?

With a high ACE score comes increased risk of addictions (all of them), mental health diagnoses (same) and chronic disease. Is this a death sentence? Should we give up? No, I think there is a lot we can do. I frame this as having “survival” brain wiring instead of “Leave it to Beaver” brain wiring. The need to survive difficulties and untrustworthy adults during childhood can set up behavior patterns that extend into adulthood. Are there patterns that we want to change and that are not serving us as adults?

This week a person said that they blow up too easily. Ah, that is one that I had to work on for years. Medical training helps but also learning that anger often covers other feelings: grief, fear, shame. I had to work to uncover those feelings and learn to feel them instead of anger. Anger can function as a boundary in childhood homes where there are not adult role models, or where the adults behave one way when sober and an entirely different way when impaired and under the influence. There may be lip service to behave a certain way but if the adult doesn’t behave, it is pretty confusing. And then the adult may not remember or be in denial or try to blame someone else, including the child, for “causing” them to be impaired.

What if someone had a “normal” childhood but the trauma all hit as a young adult? I think adults can have trauma that changes the brain too. PTSD in non-military is most often caused by motor vehicle accidents. At least, that is what I was told in the last PTSD talk I went to. Now that overdose deaths have overtaken motor vehicle accidents as the top death by accident yearly in the US, I wonder if having a fentenyl death in the family causes PTSD. Certainly it causes trauma and grief and anger and shame.

I agree with the American Academy of Pediatrics that we should screen for Adverse Childhood Experiences. We need training in how to talk about it and how to respond. I have had people tell me that their childhood was fine and then later tell me that one or both parents were alcoholics. The “fine” childhood might not have been quite as fine as reported initially. One of the hallmarks of addiction families is denial: not happening, we don’t talk about it, everything is fine. Maybe it is not fine after all. If we can learn to talk to adults about the effects on children and help people to change even in small ways, I have hope that we will help children. We can’t prevent all trauma to children, but we can mitigate it. All the ACE scores rose during the Covid pandemic and we are still working on how to help each other and ourselves.

Here is another article: https://www.aafp.org/pubs/fpm/issues/2019/0300/p5.html.

Blessings.

For the Ragtag Daily Prompt: open wound.

The photograph is one of Elwha’s cat art installations. He would pile toys on his bowl. Two bowels because I need to keep out the little ants. Sol Duc would do it too but not as often. I fed them in separate rooms. They would pile things on the bowl whether there was food left or not.

Elwha is still missing, sigh. That is a wound. The photographs are from March 2023.

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Diabetes update

Friday I attended a Zoom diabetes update all day. Sigh. We are really doing diabetes wrong.

Diabetes affected every system in the body and so the guidelines want us to check everything. They made the point that controlled diabetes does NOT lead to blindness, kidney failure, and amputations. Only uncontrolled diabetes. There, do we feel better now?

There are three NEW things to check for. One is CHF, aka Congestive Heart Failure. Heart Failure is pump failure. It makes a lot more sense if you think of the heart as a pump. Diabetes doubles the risk of heart failure in men and increases it by five times in women. We are now to do a yearly BNP (Brain Natriuretic Peptide, got that?) except that it is useless if the person is in renal failure, because that raises it artificially.

The second NEW thing is liver problems. Liver failure is back in the top ten causes of death, having fallen off that list for a while. People drank more alcohol during COVID, there was more drug abuse adding to hepatitis B and C, but the biggest cause is NASH and NAFLD. More acronyms: NASH is Nonalchoholic Steatohepatitis and NAFLD is Nonalcoholic Fatty Liver Disease. This is related to overweight and obesity. Being overweight or obese messes up fat storage and over time this inflames the liver and then cells die, leading to cirrhosis. We are to watch liver tests, think about an ultrasound, and then there are two specific tests for cirrhosis.

Third NEW thing is Diabetes Distress. This is not depression. People score “depressed” on the PHQ-9 test, but don’t respond to anti-depressants. The lecturer said that we have to talk to the patient and find out why they are distressed, or what part of diabetes is getting them down. I thought that we should have been talking to the patient all along. There is a convenient 30 question tool we can use for this, if we have time. Will we?

Now, the old guidelines said that we are to check these things:

HgbA1C every 6 months if not on insulin, every 3 months on insulin and even more in pregnant patients.

Microalbumin/creatinine ratio: a urine test that tells us if the kidneys are starting to leak albumin. They shouldn’t.

Yearly eye test to check for diabetes damage.

Specific blood pressure ranges.

Keep everyone’s LDL cholesterol under 70. So nearly every person with diabetes gets a statin drug.

Do a foot check yearly for neuropathy.

So six things plus the new three. Can’t explain that in one visit and can’t do it in one visit either. I think we should revamp the Diabetes Distress tool and check if physicians and nurses have Guideline Distress. Diabetes is the most complicated set of guidelines other than pregnancy.

Diabetes also takes a lot of time for the person who has it. To check things “correctly”, it takes a minimum of two hours a day for Type II not on insulin and more like three or more for Type I and II on insulin. Think if you have to take two or three or more hours away from your current daily activities and devote it to diabetes. No wonder people are distressed.

The medicines are also confusing. Wegovy is in the same class as Ozempic, but is FDA approved only for weight loss in people who are overweight and have a complication, or people who are obese. Ozempic is for diabetes but people often lose weight so think about it if the person is overweight. Some of the medicines in that class also are approved to reduce the risk of heart disease, which goes up with diabetes. Another class has medicines some of which have approval for diabetes and others for diabetes and renal problems, BUT don’t use it if the eGFR is under 20, got that? The lecturer on medicines said that we’ll see less in each of those classes after they fight it out for dominance of the market. He’s been an endocrinologist for 30 years and remembers when the very first non-insulin medicine was approved. Cool! He is not discouraged, but another lecturer said that we have one endocrinologist for 5000 people with diabetes, which is not enough. We were encouraged to do more continuing medical education.

There is one guideline that I disagree with and would like to see changed. I will write about that next. After I memorize all of the different things the new medicines do, which is changing every month as new research comes out! Stay tuned!

I think I will put the clutch in and coast a bit. Or perhaps clutch handfuls of hair and pull at them, I don’t know.

For the Ragtag Daily Prompt: clutch.

I hiked again yesterday and had a very cooperative bunny stop for a snack in camera range.

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Pneumonia makes me slenderize

Pneumonia makes me slenderize
I feel like I’ve been blenderized
Steals my breath and appetite
Work to breathe both day and night
My heart goes fast, trials one to four
I’d rather not have any more
Ten pounds down, gone like smoke
Carbohydrates make me choke
The legacy of my fourth round
I can’t eat gluten, ounce nor pound
And yet I still come out ahead
Since I am alive and still not dead

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Four pneumonias in 24 years. I have an antibody response, which peaks about six weeks after the infection. Colds don’t trigger it. This photograph is two months in to my 2021 round. I drop ten pounds in the first week and eating is always difficult. I do not recommend this method of weight loss.

For the Ragtag Daily Prompt: slenderize.

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Home Hurrah!

New Year’s Eve was a travel day for me, flying from Dulles to SeaTac. This time my checked bag came along and did not divert to party in Chicago, as it did on the trip out. I had a wonderful two weeks in Arlington, Virginia and Rockville, MD with old friends and my son and daughter-in-law and daughter. Very kind friends picked me up at SeaTac and drove me the two hours home. I slept for three hours on the plane and another hour in the car. The pair of socks on yesterday’s Ragtag is for one of the two people who picked me up.

The plane was about 40 minutes early and the airport was impressively empty. There was some traffic on I5, but it was not crazy. There was quite a bit of fog all the way home.

Yesterday morning we went to the climbing gym for the second time in the two weeks. I had not climbed in maybe three years? And I have never done a lot.

The rest of my family climbs like squirrels and spiders. I currently climb more like a panicked sloth, but I did a 5, a 5.6 and a 5.7 the first day. Yesterday I planned to take it easy, but I roped up for one and it was the wrong one, so I tried a 5.8. My family was clambering up 5.11s. Whew. It was really fun and loads of fun to watch them. And hurrah that I can climb some after Long Covid and two years with unhappy muscles!

Peace and joy to you and yours.

For the Ragtag Daily Prompt: Hurrah!

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Car situation

What did happen in my situation?

I am worried that a car will come around the corner and hit the car partway in the street. Plus, what if there is a medical situation? A heart attack, or drugs, or alcohol, or a seizure? I want help. I call 911. The dispatcher asks for the license plate and if I can see anyone inside. I give her the plate, but the car is fogged up, so I can’t see inside. This does make it more likely that someone is alive inside, but they could still be ill.

I wait, but I am anxious. I text my neighbor and ask if he will come back me up while I bang on the car. He comes out, but the police have just arrived. We wave and go back inside. I do peek out. There is a fairly young man and a dog, who get out of the car. He can walk without difficulty. They don’t move the car. The policeman leaves, then calls me. He says that the person is having an allergic reaction and is waiting to move his car until he can see. The car will be gone by the afternoon.

“Oh, thank you!” I say. “Can I take him coffee?”

“That would be nice.”

I go out and ask if he wants coffee. He does. I take him a cup and he leaves it on my steps. The car is gone later, so I hope he is much better. It’s lucky that he is on our side street rather than the faster main one. More chance of an accident there.

I did feel like a little old lady complaining about a strange car, but I was worrying about something medical more than a stranger. And with the possibility of alcohol or methamphetamines or opioids, I want help. We had an overdose death in our hospital parking lot within the last few years and our police have nalaxone to reverse opioids. I am very glad that it was not an overdose.

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For the Ragtag Daily Prompt: situation.

The photograph is my 1986 Honda Civic, not the car in the story.

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Found

Barbie doctor is trying to interview the Get Real Girl about the origin of the missing part in front of her, but Elwha intervenes.

“Who, me?” says Elwha. “I am trying to help! I don’t eat Barbies or Get Real Girls!”

For the Ragtag Daily Prompt: missing part.

The funny bit is that I knew right where this missing part was: on a dresser upstairs. It’s the rest of the doll that has gone missing.

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In deep

Time to return
again

Human, pfaugh
I give up
I don’t want to be one
I can be anything I want to be
I want to be a mermaid
again

I sink into the sea
and down to the depths
scales and tail and breathe the sea
the water cools the burns
my charred burnt skin
and lungs

Such a fail again
every time I try
to be human
yes, legs, I can do that
it always makes my voice hurt
but those damn wings
come with the legs

It’s hard to hide the wings.

I don’t know how
but they sense them
even when I hide them

It really pisses me off.
It’s the broken ones that show up
though now I think maybe
they are all broken
they all wander around
pretending they are ok
using lies to try to appear nice
hating parts of themselves
calling those parts unclean spirits
and casting them out
DEMON! DEVIL!
over and over

I try to pretend they aren’t there
the cast out
and I am human too
but the demons kneel and lay their monstrous heads
in my lap
crying
cluster round me
begging for my help

I always fail.

I try to stay present
with the person and the cast out
but eventually I can’t stand it
and I say something wrong
and the stupid human thinks I am the demon
and casts me out too.

I wait and hope.

I wait and hope with the monsters
with the rough beasts.
“You have wings,” say the demons, “Help us!”
“I can’t.” I say, “The humans must help themselves.”
The monsters weep and wail.
Finally I am sick of it again.
I send them home
and I go home too.
I have failed again
and must endure falling through the atmosphere
my feathers and skin a burning star

I am sick of it.
I give up, Beloved.
I am a failure.
I can’t do this.
I must go to the sea again.

Here is the trench, the deepest part of the ocean
I stop swimming and let myself sink
Slowly the light disappears
I am in the ink black

Slowly the others appear
glowing
in the deep

_________________________

For the Ragtag Daily Prompt: liquid.

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Long Covid imaging

In the last Long Covid talk that I attended and wrote about (here: Pulmonary Manifestations of Long Covid), the pulmonologist and intensivist says that one problem with Long Covid is that we do not have imaging that can “see” it.

That is, the chest x-ray looks normal, the echocardiogram may look normal (heart ultrasound), the chest CT scan may look normal, a brain CT or MRI may look normal, but the patient may still be tachycardic, feel exhausted, feel brain fog and have multiple other symptoms.

That pulmonologist listed five of the top mechanisms that are prolonged in the immune system. Most of the scientists and physicians are framing this as “immune system dysfunction”. I am not. I am framing it as “you were really really sick and your immune system is still on high alert and trying to protect you so you can recover”. Now wait, you say, how could chronic fatigue like symptoms protect me? Well, if you are exhausted, you can’t go to work and you’ll stay quiet at home most of the time and less exposure chance. But what about brain fog? Again, this will slow your interaction with other people and force you to rest and heal. But, you say, I don’t like it. Well, yeah. Patience. We call grumpy patients that are recovering “convalescents”. It is a good sign when they are grumpy and over it and just want to be better. That doesn’t mean I can make myself or anyone else heal faster.

The pulmonologist says that the best test is the six minute walk test. This is usually done by a respiratory therapist. The person walks in a circle for six minutes wearing a pulse ox, with the respiratory therapist doing regular checks. This distinguishes between the people who have primarily a lung issue from all the other issues. If the person is tachycardic (fast heart rate) but not hypoxic (oxygen level dropping), then it’s not primarily lungs though blood clots to the lungs sometimes have to be ruled out. One of the mechanisms in the immune system is microclots and an increased risk of blood clots. That can mean heart attack, stroke, or pulmonary embolus, a clot in the lungs. The microclots are suspected of causing some of the muscle fatigue and exercise intolerance, by clogging capillaries and reducing oxygen flow to muscle cells. Muscle cells do not like this at all.

I have done my own quick walk test with patients since 2003, when I had terrible influenza. About a week after my influenza started, with the temperature of 104 and heart rate at 100 at rest and 135 walking, my temperature came down. However, the fast heart rate continued. Normal heart rate is 70-100 and 135 walking will make you feel exhausted. I lay on the couch and could barely make my kids dinner for two months. It resolved then. I read a book about influenza and thought that I had “influenza viral pneumonia” where there is lung tissue swelling, reducing the air spaces, after influenza.

My quick walk test in clinic is to check a sitting oxygen level and heart rate and then have the person walk. I would have them walk up and down a short hall three times then sit down. When they sat, I watched the pulse oximeter recovery. Some people would jump from a resting heart rate of 62 to a walking heart rate of over 100, say 120. Their oxygen level could stay normal or it could drop. If they dropped below 88, I would get home oxygen and forbid them to return to work. If their oxygen level held, then they needed to rest until their walking heart rate stayed under 100 and they were no longer exhausted by gentle or normal activity. If they return to work with a walking heart rate of 120, they will be exhausted and are more likely to get a secondary pneumonia or have other problems. The heart does not like to run at 120 all the time. You can see why a person who already has some coronary artery blockage would be more likely to have a heart attack if they get pneumonia from influenza or Covid-19.

The conferences I am attending are talking about “targets” in the immune system. That is, new drugs. I think the science is wonderful and amazing, but I also think we need to step back and say, this is a really really bad infection and some people need a lot of support and reassurance and time to heal. Reassure them that even though they have not yet returned to normal, the immune system is working hard to protect them from other infections and it is saying very very loudly that they need to rest. Rest, recuperate and trust the immune system. Some things need immediate treatment, especially blood clots, heart attacks and strokes, but once those are ruled out, we need to support people through their convalescence and healing.

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The photograph is from April 2021, a few days after I was put on oxygen. A selfie.

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Forever or not?

Once someone has cancer, do they have it forever?

I think that is a complex question. But one example comes to mind.

An older woman, in her early eighties, is seeing me. She wants to go back on hormone replacement.

“But you have a history of breast cancer.” I say.

“That was six years ago. And I took that horrible tamoxifen for 5 years and I still am having hot flushes after a year off it and I am sick of it. Give me hormones.”

“Hmmm.” I say. “Let me do some research.”

I call the oncology group south of us. This is over ten years ago when we had no oncologists in our county.

“How old is she?” Her oncologist is digging up her records. “Ok, got her. Hmmm. Well, she had a stage one cancer and a lumpectomy and five years of tamoxifen. THAT cancer is gone, for sure. If she wants hormone replacement, it puts her at a bit more risk for a new breast cancer, but the old one is gone. As long as she understands the risk.”

My patient is back and we negotiate. “Ok, the oncologist says your previous cancer is truly gone, but hormones put you at risk for a new breast cancer. At least, raise your risk a little.” Age is the biggest risk in women, if they do not have the abnormal BRCA I or II genes. “Also, if we have you on hormones, you have to do your mammogram, because I’d want to catch any cancer early. That’s the deal.”

“Fine, I want the hormones.” She signs a consent that I’ve prepared and we put her back on her hormone replacement.

“I want to hear from you, ok? Whether it works?”

She calls in a week, delighted. “No more hot flushes! I feel great!”

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I took the photograph at Mats Mats Bay last week. There is a sign about osprey nests. I look up and think, oh, yes! Pretty obvious if you look up!

__________

I don’t remember her exact age and I don’t remember if the five years was tamoxifen or one of the other hormone blockers. She could have been in her seventies. At first I thought, no way back on hormones! Then I thought, quality of life is important. Maybe I choose this photograph because the nest is out on a limb.

Some cancers ARE currently forever, especially those that are stage III or IV and metastatic. Maybe they won’t always be forever.