Tag Archives: health

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Conserving energy

I was out of clinic for two years and then very part time for a year and now not quite full time as a temp. I bargained to not quite be full time.

The electronic medical record is having a consequence, along with the pressure to see more people faster. The primary care doctors, at least the younger ones, do not seem to call their peer specialists any more. (Family Medicine is a specialty, just as Internal Medicine and Obstetrics/Gynecology are.) I called a gastroenterologist and left a message last week about a difficult and complex patient. The patient had cried three times during our visit. The gastroenterologist was very pleased I had called, was helpful, agreed with my plan of using the side effects of an antidepressant to try to help our patient, and thanked me three times for calling her. Wow. I am used to calling because during my first decade in Washington State, our rural hospital had Family Practice, General Surgery, a Urologist, Orthopedics and a Neurologist. For anything else, we called. I knew specialists on the phone for a one hundred mile radius and some knew me well enough that they’d say a cheery hi.

Now communication is by electronic medical record and email on the medical record and by (HORRORS) TEXT. Ugh. I think that there is quite a lot of handing the patient off by referring them to the Rheumatologist or Cardiologist or whatever, but the local Rheumatologist is booked out until February for new patients. That leaves the patient in a sort of despair if we don’t keep checking in on the problem. If I am worried, I call the Rheumatologist and say, “What can I do now?” I’ve had two people dropping into kidney failure and both times a call to the Nephrologist was very very helpful. I ordered the next tests that they wanted and got things rolling. One patient just got the renal ultrasound about three months after it was ordered. Sigh.

I have one patient who is booked in February for a specialist. I called that specialist too, they did not want any further tests. I told the patient, “You aren’t that sick so you won’t be seen for a while. It isn’t first come first serve: it is sickest first. We all have to save room for the emergencies and sometimes those are overwhelming.” The specialist agreed and the patient is fine with that and I think pleased to know that we do not think she’s that sick. She feels better. If things get worse, she is to come see me and might get moved up. Neither I nor the specialist think that will happen.

Is this conservation of energy, to communicate by email and text? I don’t think so. I think sometimes a phone call is much more helpful, because the other physician knows exactly what I am worrying about and they can tell me their thoughts swiftly. Sometimes they want me to start or change a medicine. Things can get lost in the overwhelming piles of data and the emails and labs and xrays and specialist notes all flowing in.

My Uncle Jim (known as AHU for Ancient Honorable Uncle Jim) used to sing part of this:

Yeah, that’s just how I call my fellow specialists.

For the Ragtag Daily Prompt: conservation. Don’t cats win at conservation of energy?

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Strep A and Covid

In clinic we are seeing Strep A and Covid in the last two months, quite a lot.

Covid is all over the map with symptoms. One person had been traveling, did not feel well, but the main symptom was dry lips. Positive covid. Another was vomiting, with no upper respiratory symptoms. Some have diarrhea and upper respiratory symptoms. It interests me that flying home to Washington last month, only about three of us on the planes wore masks. I was one of them. I know people who have taken flights knowing that they have Covid, a day or two after diagnosed, so I can’t say that I trust the other people on airplanes. We are testing for Covid for almost any symptom or just feeling sick.

We are seeing Strep A as well. I saw a small child vomiting. I asked if her nose hurt: no. Throat: yes. Tummy: yes. Toes: no. She had strep A. The oldest person with strep A this week was ninety. She said, “How did I GET it?” Streptococcus is in the environment, including our throats. We may just carry it around, but then if we get overtired or stressed (good or bad stress) or have something happen, the strep can invade. We treat strep A mostly to prevent rheumatic fever, which is where our own antibodies to strep A attack us. I have seen three cases of rheumatic fever in my career. That is called a “pseudo autoimmune” disease. The strep A has cell surface markers that sometimes are close enough to ours that our own antibodies attack our body parts.

One person in the last month has a positive strep A. I write for penicillin and send her home. We call her later because the Covid/influenza/RSV test takes longer. She also has Covid! That seems like a bit much, rather unfair, but we can have two things. An initial infection can lower our immune defenses and another virus or bacteria gets hold.

Another person had tested negative for Covid, but that was four days before. Friday afternoon, so I would not get the results at home. I asked her to retest at home. Positive.

Here is the CDC page about Strep A. https://www.cdc.gov/group-a-strep/index.html

There are Strep B and C and D and so forth. Sometimes we pick them up on throat cultures. I treat if the person is still sick and symptomatic while the culture is in the laboratory.

I am wearing a mask in airports and on airplanes. I just don’t want to pick anything up, or at least do what I can to avoid it.

The photograph is Elwha in May 2023. I figure that you would rather see his tongue than mine.

For the Ragtag Daily Prompt: strep.

I think the song might be off topic. I don’t care. Beautiful.

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The isolated working

I ran my own small clinic from 2010 to 2022, working somewhere else, got Covid, was on oxygen for a year and a half, did some healing and then came back to work.

There has been a culture change in medicine that feels very strange to me. I did not notice it because I was in a solo clinic and not “part of the system”.

All the doctors, providers, are more isolated. I got a compliment yesterday when I was doing a “warm hand off” of the most sick or complicated patients, three new diabetics, a person with cancer, a person with a genetic heart problem. The doctor who I was handing off to is in the same clinic but we have barely talked since May. I don’t know her at all. She complimented me on excellent care “and calling specialists”.

I thought, huh. But I think that is a dinosaur doctor thing. I think mostly people communicate through the electronic medical record email, send messages about patients. For the decade that I was solo, I had to call other specialists because I was on a different electronic medical record. The email didn’t connect. The hospital reluctantly gave me a “link” to their system, but it was only a link to look. I could not write or send anything.

About two months ago I got an echocardiogram result. I read it and thought, ok, it’s not normal but what does it mean? Outflow obstruction by the thickened heart wall. Hmm. I called cardiology and spoke to the cardiologist who read it. He sounded surprised and said, “Idiopathic hypertrophic cardiomyopathy, most likely. It’s a classic echo.” “So, what do I do?” “Send him to me.” “Anything that I should change meanwhile?” “Yes,” says the cardiologist. He had me stop one medicine and start another. “No vasodilators and the beta blocker slowing the heart rate should help decrease the outflow obstruction.” “Got it.” I said. He also gave me two more tests to order.

I referred the patient to cardiology but it was a month before he got in. The two tests were done and they ordered more. If the diagnosis is correct, he’ll be sent to a special clinic in Denver. I called my patient while we were waiting for the cardiology visit. The medicine change had not made much difference as far as he could tell.

I was also told when I got here that I would never get a local nephrologist to see a patient, they were two busy. However, I have called two nephrologists about two patients and both took the patient and again, gave me instructions.

Two specialties have been very difficult to contact: orthopedics and gastroenterology. I have no idea why they are so difficult.

I can see that email feels faster. But there is no human contact, asking follow up questions is difficult, I don’t get that bit of further helpful education: this is what you do next. I have learned so much over the years by touching base with specialists. Once I fussed at a patient to go to hematology oncology about their high platelet count. The patient didn’t want to. He came back and said, “Apparently I have this newly found genetic problem. They put me on two medicines, not expensive. And I feel better than I have in 20 years.” I asked the oncologist about it the next time I called. He lit up, excited, and told me about the JAK-2 mutation. It is so exciting to learn about new areas in medicine and my patient says, “I have to thank you for pushing me to see the oncologist. I feel so much better.” Wow and cool.

Clinic feels like I am mostly isolated, a silo, an island, rarely talk to the other physicians unless I go to find them. I think hospital administrations like this, keeping the physicians in line by having their schedule be so packed that they almost never talk to each other. What a good way to keep physicians from interfering in the money making production! Ugh, I think it is quite horrible and unhealthy for the providers and for our countries medical system in the long run. I was seriously less lonely in a solo clinic.

The prognosis for our current medical system is very poor. The patients say to me, “Why do my doctors keep leaving?” They aren’t attached, they are isolated, I don’t think the physicians know what they are missing. Colleagues. Not silos.

For the Ragtag Daily Prompt: prognosis.

The photograph is from the Fruita Fall Festival.

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Bolster meaning

It did not even occur to me that yesterday’s dream could be taken as complaints about patients! That was not my meaning!

I wrote the dream out because I wanted to know what it was trying to tell me. And I look at it from the perspective of all the people in the dream being aspects of myself.

So who is the whiny guy (me) who won’t cooperate with authority (me) and who wants attention and is difficult? That’s not a very nice aspect of myself!

First of all, he reminds me of my father. My father really did not like authority and did not like most men. When I was quite small, I announced that he would have to die first, because he couldn’t live without my mother, but she could live without him. I was wrong as well as being an awkward child. My father’s dislike of authority interfered with his employment and he was mostly underemployed. He finished a Master’s in Mathematics, but never wrote the thesis for his PhD. I asked him why once and he said, “I was bored.” I don’t know how much alcohol interfered with his working.

I am not brilliant with authority either, though I am trying. I notice systems and often annoy authority by asking why something is run a certain (foolish and unproductive) way. I used to study whatever system I was in and then say, “Here, I’ve thought up a solution for this problem.” Then I would get in trouble for suggesting that there was a problem and I would be the problem. I learned to go to authority first and ask, “So is this (huge problem) a problem? I find it difficult. What is your advice?” Priming the pump, so to speak.

As a temp, the authority problem is weirder. I am an outsider, short term, no one really has to be nice to me. That fast trip home and back made me realize that I am lonelier in a group clinic than I was in a solo clinic. In my solo clinic there was me, my receptionist and the patients. In this group clinic I have less people to talk to and it is lonely. My problem, not theirs. They are about to move me to another clinic and I will see what approach I can take to this. The system might have a Balint Group or I may be able to start one.

What about the frozen looking spouse? Ha, I think that’s the part of me that is trying to keep my mouth shut with authority. The kids? Some days I want to pull the system apart and fix it, but I am not in authority to do that here. The grumpy nurse? I am running behind and I can’t fix everyone. Some people don’t want to be fixed, including me.

I could go home and try another place. However, I think that the cracks in the US medical system are in the whole system. As a country, we built this. I hope that I see single payer healthcare in my lifetime, but I may not. And Martha is right too: I thought that this place was doing better handling a chronic illness than where I worked in 2021, but they aren’t, really. They apply a formula, but the patients don’t get much out of it. They just get shuffled in once every three months. I did upset that apple cart by spending more time with those people and talking to them, but I do not know what the next physician will do. Sigh. The patients are already my patients and are saying goodbye.

For the Ragtag Daily Prompt: meaning.

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Sisyphus

Sometimes clinic feels a bit like Sisyphus must feel. Rolling the stone of illness up the hill but it is eternally rolling back down. I can’t stop it. People age and people die and otherwise there would be no room for young ones.

The last two weeks of clinic has worn me out a bit. A friend says that I take too much of it home, worrying about people. How to let go of this?

I make connections in clinic. Not all the time. Sometimes I fail. I made a connection with more than one person with diabetes this week, but one was funny. The connection is that he mentioned that he is an elk hunter. Oh, and flies to California to fish and has a very lot of fish. I said that I’ve had elk and like it. That was when the connection engaged: he was very pleased that I am not horrified by hunting. Hunting elk is not at all easy or cheap and cleaning the animal and carrying it out, well. He is coming back about his diabetes and left cheerful.

If I go home trailing those connections and spend my time worrying about this people, I’ll wear out. I don’t want pneumonia number five. So how do I connect but let it go when I go home?

I will think of the connection as much smaller than the boulder that Sisyphus deals will. Not a boulder. A small piece of the rock. I can suggest how the person can lighten the load a little. Then I must stand aside and let them go. They have to decide what to do about their health. It is between them and the Beloved, they can try what I say or not.

Now it is not a boulder that I am trying to keep from rolling down a mountain. Each person has their own mountain to climb in their life, their own habits and histories, good or bad, trailing them like Marley’s Ghost in A Christmas Carol. I can suggest a tool to loosen a link of diabetes, or a slightly different trail up the mountain. Then it is up to them. I can’t carry them and should not carry them. Maybe they are approaching a patch of scree and I can suggest an easier or safer path. And then stand aside, stand down, let the people go.

Now I am not pushing a huge rock. I am standing on my own mountain, quiet, and looking at the path behind. I am resting a little and on my own path. I don’t know what will be around the next bend in the path. But I love the mountain and the forests and the birds and the ocean. All of it.

Thank you, oh Best Beloved.

For the Ragtag Daily Prompt: olympics!

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On line weight loss drugs

Don’t buy it. Apparently a company call Him is selling a compounded GLP-1 like drug, have worked around the DEA for the moment, but people are getting really sick and there have been some deaths. Article here.

The workaround is that the DEA will let compounding pharmacies make a drug if there is a shortage. Unfortunately, online companies are doing 734,000 prescriptions a month. People can get them on line without a doctor visit or labs, though there may be a doctor signing off. Remember that they are selling an untested GLP-1, and the side effects of the tested ones can include gall bladder disease, pancreatitis and gastroparesis, where the food sits in the stomach and doesn’t leave. And yes, there have been deaths. This may be the salt of the drug, so that it doesn’t have the slow absorption when injected, and hits all at once. Is weight loss that important?

The guidelines for weight loss drugs are here: https://www.aafp.org/pubs/afp/issues/2023/1000/practice-guidelines-medications-weight-loss.html. This article is from October 2023, so doesn’t have the latest offering. I recently saw a person who did not fall into those guidelines. I refused to prescribe. The person responded, “I’ll go to Mexico and get it.” I reply, “Be sure that they do laboratory work and talk to you about the potential side effects.” I am also reading that now there are faked weight loss injector pens circulating. I don’t know what is in them. Fentanyl? Floor sweepings? Who knows.

Meanwhile I am still working on a little weight loss myself. I don’t know if I’ve lost much but clothes are fitting better. The climbing gym and hiking are having an effect. Muscle burns 9 kcal per gram and fat only 4 kcal per gram, so building muscle slims one even if the weight stays the same. My endurance is rising. That feels so good after being on oxygen for a year and a half. I am still trying to eat 1/2 green/yellow or orange vegetables at each meal and I think that is helping too. All this discipline stuff, eeyuk. Oh well.

Anyhow, be careful out there. I do not recommend getting weight loss drugs off the internet or buying it from “friends of friends”. Bad news.

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Food, food, food

When I get pneumonia, I drop ten pounds the first week. Since I had influenza viral pneumonia in 2003, I don’t run a fever. I just have a fast heart rate resting and get short of breath walking across the room. With Covid, I needed oxygen.

Each time, it takes longer to gain the weight back. Then I go over my normal weight and eventually have to rebuild muscle. This time I did not gain any weight back for over a year. But now it’s been three years and I am in the muscle rebuilding and weight loss section.

It does get harder as I get more mature. Older and wiser, right? Well, maybe. At any rate, I am trying to lose weight without any drugs or injectables or herbs. I am trying to eat the way the diabetic educators tell us to: half the meal should be vegetables. Every meal. A small grain and a small protein and not too much fat and vegetables. Corn really falls into the grains.

In clinic I often do a diet history of the day before. What did the person eat? I think about half of the histories come back with almost no vegetables. Pizza is NOT a vegetable, it’s mostly in the grain department. Grains are plants, I agree, but they send blood sugar up a lot more than celery and kale and collards.

Meanwhile, where is CHOCOLATE on that plate half covered with vegetables? Darn. My dessert could be a small piece of chocolate with a carrot on the side? Chocolate dipped carrots? I honestly do not like celery. Celeriac yes, celery no, though I have it in the curried chicken salad I made yesterday. That chicken salad is not half vegetables. It has some celery for crunch but it also has grapes. So, I ate it last night with an equal amount of mixed lettuce and sugar snap peas from the Farmer’s Market.

I do not have diabetes, but if I am recommending a dietary change, I think I should be able to do it too. We shall see. I think right now my diet is about 1/3 vegetables. Fruit does not count as a vegetable for this.

The other thing about vegetables is you have to cut them up. Ok, wash them too. And it’s not like one doesn’t have to cook beans or rice or meat, but vegetables do take time. If I have a person with low blood sugar or who is feeling awful, saying make half the meal vegetables may not be realistic. When someone is really frail or ill, it may be that getting out of bed, washed and dressed and to the table is overwhelming. Cut up vegetables? Cook from scratch? Maybe not.

For the Ragtag Daily Prompt: lunch.

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Covid Morph

So far I have gotten positive Covid tests on one patient a week, all with really different symptoms.

One older person who was short of breath walking, tired, coughing and loose at the other end.

One young one whose only symptom was profuse throwing up.

One with a sore throat, nasal congestion, cough and feeling fairly awful and about to go on a trip, darn it.

There isn’t a nice pattern to tell me what the local strain is doing. It can do any darn old thing. I have also seen someone with strep throat and another couple who had similar symptoms to the others but did not have Covid. It’s morphing like an AI, I swear. I am masking in clinic but so far so good.

The Ragtag Daily Prompt is essential. I think it’s pretty essential for me to wear a mask in clinic, in crowds and on airplanes, since I am quite tired of pneumonias.

I have been the only “provider”, that is, doctor, in the clinic for the last two days. The medical assistants and front desk and I are starting to work as a team. I ask the front desk person how to communicate with her from the clinic room most efficiently. Something was weird about the refill system and it kept refusing refills. On Tuesday I had over 100 “documents” in the computer “box”. Lab work, specialist reports, refill requests, x-ray reports, nursing home things, surgery reports, wound clinic, emergency room, and so forth. I am trying to skim them, but I can’t say that I will remember person A’s dermatology report after skimming 60 others. If you go to your primary care provider and have had some major medical thing recently, remind them. They may have gotten and read the note, but gosh, it’s hard to remember at 100+ per day. Right now I have not met most of the people, so it is even harder.

The photograph is just for fun, taken a few weeks ago on the trail that runs by the Colorado River. Lovely!

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G6PD deficiency and diabetes

Today I follow an online trail to this article on diabetes from Nature Medicine here.

It is talking about a genetic variant that is found in people with African-American heritage called G6PDdef. This genetic pattern makes the HgbA1C test inaccurate. It will look low and “in control” even when blood sugars are high. Since the blood sugars are NOT in control, complications from diabetes can happen: damage to vision, to kidneys, to nerves in the hands and feet.

I have been reading articles about current and changing guidelines about diabetes. The current guidelines say that checking blood sugars at home doesn’t make a difference. I REALLY disagree with this and at the same time, I don’t think that physicians are approaching blood sugars in a practical manner.

I saw a man recently who is diagnosed with “insulin resistance”. His HgbA1C is in between 5.6 and 6.0. Normal is 4.5 to 5.6. Over 6.5 is diabetes. He has prediabetes. He has not checked blood sugars at all, but he is on metformin.

There is evidence that metformin is helpful, and still, I think it is putting the cart before the horse. I ask my people to go buy an over the counter glucometer. Ask for the one that has cheap strips, 6 for a dollar instead of a dollar apiece. Then we go over the normal and abnormal blood sugar ranges and I ask them to start checking blood sugars. If I give them a medicine right away, they don’t learn how to control their blood sugar with diet. ALL of my patients can figure out how to bring their blood sugars down with diet. If we can’t get to a good range, then we will add metformin. I do explain that the guidelines say use a medicine right away, but I ask, “Would you like to see if you can control your blood sugars with diet?” The answer is overwhelmingly “YES!” I have never had someone say no. If we do not give them the chance and explain the goals, why would they even try?

Also, I read the dietician handouts for diabetes yesterday and I am not satisfied. I do not think they explain carbohydrates well. Foods have fats, proteins, and carbohydrates, and anything that isn’t fat or protein has carbohydrates. I think of carbohydrates as a line, from ones with high fiber that do not send the blood sugar up fast, to ones that shoot it way high. At the low end is kale and lettuce and chard and celery. Then the green and yellow and red vegetables that are not sweet. Then beets and sweet peas. Next come the fruits, from blueberries up to much sweeter ones. Fruits overlap with grains: bread and pasta and potatoes and rice. The whole grains have more fiber and are slower to digest. Candy then sweet drinks (sodas are evil) and sugar.

Sugar has 15 grams of carbohydrate in a tablespoon. Kale has 7 grams of carbohydrate in a cup. That’s a pretty huge difference. A small apple has about 15 grams of carbohydrate and a large one 30 grams. Read labels for grains. There is a lot of carbohydrate in a small amount. The issue with fruit juice is that most of the fiber is gone, so the sugars are broken down and absorbed much faster. A 12 oz coke has 32 grams of carbohydrate and a Starbucks mocha has 62! I quit drinking the latter when I looked it up.

Most people with diabetes are supposed to stay at 30 grams of carbohydrate per meal, or 45 if it is a big person or if someone is doing heavy labor. Snacks are 15 grams.

Avocados are weird. They have about 17 grams of carbohydrate in a whole one, but they also have a lot of fat. They do have a lot of fiber, which surprises me.

Diet control takes a combination of paying attention to what is on the plate and serving amounts. Three servings of pasta is not going to work, unless you are out fighting forest fires or are on the swim team. Fire fighters are allotted 6000 calories a day, but most of us do not get that much exercise.

At the same time that articles are telling me that home blood sugars are not useful with a glucometer, everyone is pushing the continuous glucose monitors. I think we like technology. And other articles say that diabetes can be reversed with major lifestyle changes.

Articles: about not using home glucose checks, here. Starting metformin, here. Starting with one of the newer medicines, here.

I think people feel a lot more successful if they get a glucometer and can bring their blood sugar down by messing about with diet. I tell them to check after what they think is a “good” meal and after a “bad” one. How much difference is there? Contrast that with being handed a pill to control it, while someone talks about diet and says all the same stuff that we’ve heard for years. Nearly all of my people want to avoid more pills and are willing to try a glucometer to see if they can avoid a pill. People who have been on diabetes medicine for a while are less willing to try, but sometimes they do too. And sometimes they are surprised that some meals do not do good things for their blood sugar.

This is all type II diabetes. For type I, we have to have insulin. If type II has been out of control for a long time, sometimes those people have to have insulin too. Right now insurances will usually cover continuous glucose monitors for people with diabetes who are on insulin, both type I and II. I do hope that they really make a huge difference for those people!

The spectrum from the low carbohydrate vegetable, the green and yellow and orange ones, up to the really high simple sugar ones is also called the glycemic index. There are lists of low to high glycemic index foods. Perhaps some people with diabetes find that helpful, but I think it’s simpler to say, ok, the stuff that doesn’t taste sweet will send the blood sugar up less. Also, since we are all genetically different and then our gut bacteria and microbiome are all different, it is individualized care to say how does this person at this time respond to this food? We change over time!

There are other examples of the HgbA1C not working to track diabetes. A resident and I looked over a person with diabetes and spherocytosis. The HgbA1C was nearly normal but the blood sugars were in the 300 range. Spherocytosis is a genetic blood cell abnormality, and the red blood cells don’t live as long. People with a past bone marrow transplant also have red cells that live for a shorter time. The G6PD deficiency is thought to help people survive malaria, so persists in the population, like sickle cell anemia. Isn’t genetics fascinating?

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Lie low and flow

We have fight or flight for the sympathetic nervous system state, when we are ramped up, aggressive, go getters, all that stuff. We need a term for the parasympathetic nervous system state, the relaxed one. So far I’ve come up with lie low and flow. Other suggestions? I welcome them! We need more lie low and flow and glow and say no and ho, ho, ho in the world. What puts you in that state? Knitting? Stupid cat videos? Bugs Bunny? A bubblebath? Watching toddlers? What makes you laugh and yawn and relax and lets all the tension flow out and sink or float away?

In clinic I am seeing a wide age range. Most of the younger ones, say, under 60, look a bit shell shocked. I think this is still from the pandemic and wars and political nastiness. The over 60 crowd seems to not care as much. They’ve been through it, they know people die, they know bad stuff happens.

A friend and I were talking about pandemics and he pointed out that HIV and AIDS was a pandemic too. So we are on track for two pandemics per century. The younger folk do not remember the HIV and AIDS pandemic and how frightening it was. Right before that started, some doctors proclaimed that infectious disease had been conquered by medicine. Um, RONG RONG RONG! Boy did they eat THOSE words. And early in that pandemic, no one knew what to believe, what was happening, how to stay safe, and the communication from the medical establishment changed very fast. I wonder if the people who were young adults and older in the 1980s were less surprised by the Covid-19 Pandemic and all the rumors and confusion. Yep, seen it before.

I am not sure how to help the younger shell shocked looking folks. Colorado is a bit tough and manly and consequently there is not a huge amount of resources for emotional health. Yesterday I asked if we have anyone who does neuropsychiatric testing and the answer I got was “I don’t know.” I will dig around today but did not find it on the internet. I have found neuropsych testing hugely helpful for traumatic brain injuries, post brain surgery, and to sort out unusual learning and memory styles. One woman had a brain tumor removed. Her memory was affected. She could remember things that she wrote down and read, but not things that she only heard. No one had given her the report to read. They only told her, so she did not remember it. At least, that was the story. I gave her the report and said, “Read it. And tell your family. And if you are on the phone, take notes.”

Ok, now I should get ready for work, though I want to lie low and watch a silly cat video.

For the Ragtag Daily Prompt: yawn.