Well, that’s the way it is.
The picture is from Lake Matinenda in Ontario.
Well, that’s the way it is.
The picture is from Lake Matinenda in Ontario.
I drop the fragment of rock with the seam a second time. Now I have three pieces. I stop there. When I climb back up the bank, I have an oxygen tank, a camera and rocks. It involves quite a bit of swearing and stopping to rest while I try to get enough oxygen.
Hopefully I will get better. I don’t know when or even if. My friend B says he wants to know what the pneumonia was, that triggered this round of pseudoautoimmune misery. I shrug. “We know some things it isn’t.” I say. “It isn’t covid-19, it isn’t influenza A or B, it isn’t respiratory syncytial virus, it probably is not strep A though I still haven’t had the second blood test. It isn’t pneumococcal pneumonia. It could have been mycoplasma pneumonia or pertussis or a very long list of viruses. Doctors are practical scientists, at least, I am. If the patient is getting better, don’t chase an answer that won’t add anything. I caught something, probably in the clinics where people kept taking off their masks when they were ‘alone’ in the room. They didn’t realize that they were breathing out viruses or bacteria that could take me out.” We aren’t exactly sure if the combined penicillin and clindamycin, high dose, helped or not. I think it did, but stress makes this worse too and it was a very very stressful time. Mean people, you know, and mean family. I just don’t understand what they are thinking.
I really think that post covid-19, we should wear a mask if we go out in public when we are sick. Because you don’t know which people are the vulnerable ones. I normally have lots of energy and I don’t think people would guess that I have had chronic fatigue and that I am terribly vulnerable to infection. In the clinic I owned, after I was sick in 2014, I asked any patient who was sniffling or coughing to wear a mask. “I get pneumonia easily,” I would explain. They had the right to refuse and then I would not see them. After I closed my clinic and went to work as a temp doc, I could not protect myself. I asked the nurses to ask people to PLEASE keep their masks on, but people are people. They didn’t. I had a bit of a PTSD reaction every time I walked into a patient room and they had masks off. I wanted to run out of the room screaming but I was more restrained and just said, “Please, please, PLEASE put your mask back on, other people have been in the room.” I didn’t add “And you might kill me.” because I only had 20 minutes for the visit…..
The pieces of rock are beautiful, aren’t they?
Here is a great song. Got it from this blog: https://reflectionsofanuntidymind.blog/2021/05/07/icky/
This is all for the Ragtag Daily Prompt: workshop. I like working with rocks. I have to decide what work to do next, since it’s no longer safe for me to do family medicine. It SUCKS. I really miss my peeps.
I have to get well first. If I do, what next?
I pick the rock up and drop it on another rock. Inside there is a vein of quartz. And what looks like a heart, made of quartz. Beautiful. I hope the rock does not mind being broken. I am questioning myself. The rock would break eventually but I have speeded that up. Sometimes we do some really questionable things out of curiosity.
The rock did not break along the seam that I expected it to. There is still that seam. Should I drop it again?
For the Ragtag Daily Prompt: workshop.
This year influenza is bad. My key test in influenza is not a chest x-ray. It is taking a resting pulse and a walking pulse.
Why? Influenza can cause a walking pneumonia. Walking pneumonia is where the lungs are infected throughout and there is tissue swelling. It is different from a lobar pneumonia. In lobar pneumonia people run a higher fever, look sicker, and on the chest x-ray, that part of the lung is white: infection, not air.
In walking pneumonia, the chest x-ray may be read as normal. This is because all the lung tissue is equally swollen. The swelling means that there is less air space. The person may feel ok at rest. They feel exhausted when they walk because the heart must take up the slack for the missing air space, the swollen lungs. At rest this week one person’s heart rate is 84. After walking it is 124. Normal is 60-100, so 124 is like running a marathon: exhausting and hard on your heart and body.
I have patients saying “I was sick two weeks ago and I am still exhausted.” If their pulse is much over 100 after they walk, they cannot work until it comes down. If they work and wear themselves out, the lungs can’t heal. The treatment is rest. If they are at work with a pulse of 114 or 124, then they risk getting a secondary infection in already damaged lungs. They could die.
Check your pulse at home. Count the number of heartbeats in 60 seconds. That is your pulse. Walk around, sit down, and check again. That is the walking pulse. Over 100 is not normal.
This is a bad influenza. The tamiflu (oseltamivir) helps but works best in the first three days of flu. Check your pulse, be seen, rest and get well.
For the Ragtag Daily Prompt: key.
I don’t know why this picture is a key. It’s a mystery. You tell me why, I don’t know. Because the bush has started it’s spring growth and is covered with snow? Because the snow means winter and winter means spring and life goes on even when things are difficult or even horrible. Still, winter comes and then spring.
And this photograph wants to be part of the mystery too. I don’t know. Explain it to me.
For the Daily Prompt: infect. Maybe heart and brain health could be an infectious idea…..
Heart disease is the number one cause of death in the US, around 24% of deaths every year. Strokes are fifth most common cause of death at 5%, dementia sixth most common at 3.6%, data here from 2014. Accidents have beaten strokes out for fourth place because of “unintentional overdose” deaths.
I did a physical on a man recently, who said what was the best thing he could do for his health?
“Reduce or better yet quit alcohol.” is my reply. Even though he’s within “current guidelines”. I showed him the first of these studies.
Two recent studies get my attention for the relationship between the heart and the brain and alcohol.
In this study: http://www.onlinejacc.org/content/64/3/281, 79,019 Swedish men and women were followed after completing a questionnaire about alcohol consumption.
They were followed from 1998 to 2009 and 7,245 cases of atrial fibrillation were identified. The relative risk for atrial fibrillation was alcohol dose dependent: that is, the people who did not drink had a relative risk of atrial fibrillation set at 1.0. At 1-6 drinks per week the risk was 1.07, at 7-14 per week the risk was 1.07, at 14-21 drinks per week 1.14 and at >21 drinks per week 1.39. They also break it down by number of drinks per day. So why do we care about atrial fibrillation? “Atrial fibrillation (AF)/atrial flutter (AFL), the most common cardiac arrhythmia, is accompanied with a 4- to 5-fold increased risk for stroke, tripling of the risk for heart failure, doubling of the risk for dementia, and 40% to 90% increase in the risk for all-cause mortality.”
Atrial fibrillation, stroke, congestive heart failure, dementia and 40-90% increase in all-cause mortality. Want to protect your brain and live longer? Quit alcohol.
Well, that instantly decreased my enthusiasm for alcohol, now down to one drink per week if that.
In the 599 912 current drinkers included in the analysis, we recorded 40 310 deaths and 39 018 incident cardiovascular disease events during 5·4 million person-years of follow-up. For all-cause mortality, we recorded a positive and curvilinear association with the level of alcohol consumption, with the minimum mortality risk around or below 100 g per week. Alcohol consumption was roughly linearly associated with a higher risk of stroke (HR per 100 g per week higher consumption 1·14, 95% CI, 1·10–1·17), coronary disease excluding myocardial infarction (1·06, 1·00–1·11), heart failure (1·09, 1·03–1·15), fatal hypertensive disease (1·24, 1·15–1·33); and fatal aortic aneurysm (1·15, 1·03–1·28). By contrast, increased alcohol consumption was log-linearly associated with a lower risk of myocardial infarction (HR 0·94, 0·91–0·97). In comparison to those who reported drinking >0–≤100 g per week, those who reported drinking >100–≤200 g per week, >200–≤350 g per week, or >350 g per week had lower life expectancy at age 40 years of approximately 6 months, 1–2 years, or 4–5 years, respectively.”
Ok, over half a million people followed, 40K+ deaths, 39K+ heart events (heart attack, atrial fibrillation, new congestive heart failure, etc), that’s a pretty impressive study.
A 5% 12 ounce beer is 14 grams of alcohol. Here: https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink. Our local brewery and pourhouse usually serve pints, 16 oz, and the range is from 5% to over 9% alcohol. Two 9% pints is how many standard drinks? You do the math. Currently the recommendations in the US are no more than seven drinks per week for women (98 grams) and fourteen for men (196 grams) per week, no saving it up for the weekend, no bingeing. The UK stops at 98 grams for both men and women. The rest of Europe goes higher.
Heart and brain, how I love you! I like my brain and don’t want to pickle it. I think I’ll choose heart and brain over alcohol, long term over short term, health over escapism.
Have a great week!
I took the photograph. It reminds me of neurons in the brain.
For the Daily Prompt: meager.
I think my heart is too small to hold this beauty for long. It rushes off to other things. “Come back,” I say, “stay here….”
A visual guide to the new hypertension guidelines: https://www.medpagetoday.com/cardiology/hypertension/69399
In writing: http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults
I don’t watch television news, so I always hear about these things from patients first. “What do you think of the new hypertension guidelines?”
“Haven’t heard about them yet, so I don’t know.” Seems pretty embarrassing really, doesn’t it? Shouldn’t I be alerted as a doctor before it hits the news?
First of all, these guidelines are NOT JNC 9.
What is JNC 9, you ask?
One of the messy complications of medicine for people in the US and in the world, is that there is not ONE set of guidelines. There are multiple sets of guidelines. Take mammograms, for example. The US Preventative Task Force* said that the evidence in their review could not differentiate between yearly and every other year mammograms. They said you could do it every other year. The American Cancer Society and the Susan Koman Foundation yapped and had different guidelines, do it yearly. So as a physician I have to not only pay attention to the guidelines but know who is putting them out. The radiologists wanted yearly mammograms too, surprise, surprise.
And do you think some of it is driven by money? Well, it’s the US.
JNC 8 is the Eighth Joint National Committee and put out guidelines in 2014. Their job is to review all of the big hypertension studies since JNC 7 and put out new guidelines. JNC 8 took over a year, was multidisciplinary, and the final document was 400+ pages.
They said that if a patient was over 60, their blood pressure should be taken standing up, and the goal was under 150/90. Under 60, sitting, goal under 140/90. Normal is 120/70 and below.
Then there are pages and pages of recommendations about which medicines to use and in special circumstances, that is: diabetes, kidney failure, heart disease, atrial fibrillation, etc, etc.
The cardiologists promptly started yelling about how JNC 8 is wrong and they put out a huge study saying that people have less heart attacks if their blood pressure is 125/80 or below.
But… the heart is not the only organ in the body. My patients are 77% over age 50 and 48% over 65. Once a person hits 80, their blood pressure may drop when they stand up. Most do. And low blood pressure, well, it’s bad for the over 80 crowd to get poor blood flow to the brain or to the kidneys or to faint and break things. That is why JNC 8 is multidisciplinary: because we need geriatrics and psychiatry and ortho and family medicine to be part of the guidelines.
So these NEW and IMPROVED guidelines. Well, who is putting them out? American Heart Association, American College of Cardiology, and a bunch of other mostly heart related organizations. And they are comparing it to JNC 7, not JNC 8. JNC 8 is being ignored. This document is a mere 192 pages, with the “short” version being 112 pages.
It says that blood pressure 130/80 to 140/90 is stage I hypertension, not prehypertension, and that we should treat it with lifestyle changes. Drugs are still to be recommended at anything over 140/90, though honestly, I start with lifestyle there too. Over 180/120 is now “hypertensive crisis”, consult your doctor immediately. 140-180/90-120 is stage II hypertension.
How will this change my practice? I am still thinking about the new guidelines and who has skin in the game. The AAFP (American Academy of Family Practice) put out a link to the guidelines and then a cautious comment to the effect of “We are studying how we should respond to this.”
Before this came out, I would tell people the JNC 8 goals. I do stand the people over 60 up, most of the time. I also tell people that the cardiologists want their blood pressure lower. And then that the cardiologists mostly ignore hypertension and cholesterol guidelines anyhow. If I follow the guidelines and then the patient sees a cardiologist, the cardiologist usually changes something. Guidelines be damned.
It comes down partly to a patient’s goal. I have people come in and say, “I don’t want to die of dementia!!” I see that as an opening. “What DO you want to die from?” People have different ideals. Some say, “I don’t want to die!” but then many do think about it. Sometimes this changes their ideas about what they want treated and what they don’t want treated.
Not everyone’s blood pressure drops in their 80s. Some people develop hypertension in their 90s. I tell them. They say, “I’m not taking a drug!”
I reply, “Let’s talk about strokes.”
They usually are not afraid of sudden death, but they don’t want the disability of a stroke. Many choose medicine after all.
One of the issues with guidelines is complexity. I could spend 20 minutes with a patient just talking about hypertension guidelines and choices of drugs and side effects and why they should be on an ace inhibitor or ARB if they have diabetes…. and there are guidelines for EVERYTHING. Sometimes conferences feel like all the specialists yelling: only half of diabetics are controlled, only one third of hypertensives are controlled, family doctors aren’t screening for urinary incontinence enough, osteoporosis, lung cancer, stop smoking! And then what my patient really needs is to talk about their adult child, in jail for addiction, and how frightened they are about overdose and the grandchild and the future…..
JNC-8 flowchart: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf
*lots of guidelines: https://www.uspreventiveservicestaskforce.org/
still in my heart
why are you there?
you have sold me out
more than once
disappeared when I was sick
returning when I was better
long after I stopped being contagious
and noted when the news caught up
with what I’d been saying about opiates
she’s been talking about this
you say to others
I realize that you did not believe me
until the news agreed
another with words
“If you make me choose
I will choose her.”
I think “you just did.”
do you hear?
that is a threat
to shut me down
to shut me up
to shut me out
you won’t choose
I choose now
I walk away from your threat
another tells me to visit
and talk about her dead
she has refused to talk about
for five years
how can she ask me
to talk about hers?
I walk away
kicking the falling leaves
I carry each of you
in my heart
as the space between us
For Mindlove’sMisery’s Sunday Writing Prompt #288.
Over the Rhine: All of my favorite people.
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