Tag Archives: outdoors

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Perspective: beneath the clouds

Beloved why?
I am glad for your love
and warmth
and connection
and my cat’s
and my adult children
friends
family
patients
work
and why? Beloved

A high Adverse Childhood Experience Score
Two alcoholic parents
One sick with tuberculosis through pregnancy
Letters from the hospital to her mother
After birth
Never mention me
As if I do not exist

She told a story that she dreamed
she gave birth to kittens
played with them
and gave them away

Not a dream of joyously welcoming her new baby
Me.
Yet I didn’t hate her or my father
My damaged parents
My damaged sister
Who followed their path, not mine
There was nothing I could do
Only three years old when she was born
Try to shield and mother her
As best I could

Why Beloved
I have tried so hard to grow
to love
to forgive
and yet I have no human lover

My cat jumps on my notebook
And interrupts this writing
She is happier to welcome me home
Than any man I’ve ever dated

My daughter’s boyfriend picks her up
at the airport and has made her dinner

If I am a failure at love with a partner
Or too smart or damaged or difficult
To love
For humans
At least my children have both found love
And if I were to choose me or them
Yes, I’d choose them

Is that why, Beloved?
Sacrifice to heal the next generation?
It is worth it.

And yet, that small child part of me
That even as a toddler thought the adults were unpredictable, dangerous, mean when drunk as they laughed.
She is angry at them, Beloved
She is angry at you, Beloved
Or at people
Or at the universe
She still believes in every cell, in her bone marrow, in the vast universe in her mind

that she too could be, should be

loved.

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Dissolution

I am sorting, Beloved.

I dream that my sister has drowned
in the ocean. A sailboat went down.
There were others on board.
Two friends ready me to dive and find her.
I don’t want to scuba dive, I am not trained.
I don’t know how to use the equipment.
I am afraid I will drown too.
I see her daughter, who is four.
Her daughter knows from my face that her mother is lost.
My friends say, “You will be able to find her.
You can find your sister.”
“But she is dead,” I say.
“I don’t want to find her.”
I know that they are right, I could find her.
But I might be separated and lost, in the depths.
I don’t want to die too.

I wake up.
The dream sticks.
My friends wanting me to wear a borrowed wetsuit
and scuba gear and go down untrained.
My sister floating in the depths, dead eyes open.
But she has been dead for years, I think.
And this is the sea of dreams
my unconscious
the greater unconscious
everything.
So why isn’t my sister’s body dissolving?
Changing to a skeleton.
A skeleton coming apart over the years.

I don’t need a wetsuit
or scuba gear
to dive in the sea of dreams
I can breathe in the unconscious
I have been to the bottom of the sea
many times before.

My niece is four in the dream.
She was thirteen when her mother died.
I think she was lost to me long before that.
The dream knows.
Her mother was lost to me
when my niece was four.
Drowned.

When the dream returns
I will say yes to the dive
I love the sea and the ocean and going deep
I don’t need a wetsuit
I don’t need scuba gear
I don’t need to find my sister’s body
She is gone
Dissolved
I let my past go.

I have not dreamed of the ocean

since.

__________________________________

I really don’t know where my sister is, because of the family schism after she died. Are her ashes somewhere?

This poem wanted to be born. For the Ragtag Daily Prompt: Who knew?

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Done and undone

I am done with my third Grand Junction travel doctor assignment and packing to go home. I don’t think much of my temp company at the moment. I had to nag them for two weeks regarding the travel plans. I had to call both airlines (one hour 18 minutes and one hour 38 minutes) to be sure that taking Sol Duc on board the plane is arranged (it wasn’t). I called the hotel for the day between planes and they do not take pets. I called the company that takes me from the airport the last two hours home and they DID know about the cat. One out of four. They finally switched the hotel on Friday, the last day of work.

Then at 5:18 pm I am sent an email saying I have to vacate on the 19th. The first plane is on the 21st. It was sent by the rep who is covering me and knew the travel arrangements are for the 21st. I am glad that I pay way more attention to detail as a physician than they do to my travel and housing. They frankly suck. And I am not vacating until Monday. They may charge me at which point I will say they need to pay me for spending more than 5 hours fixing their travel screw ups.

I did say to the rep on Friday, “Well, if it’s not arranged today, I will just call the emergency travel line at 5:01 pm. They will help me.” The emergency travel folks cost them more money. That apparently caused them to do the last arrangements. I am doing the travel in two days because otherwise my cat would be in the carrier for 12 or more hours. That is not reasonable.

I am done except for travel home. Today I finish packing and cleaning.

The photograph is Sol Duc in front of our rental house yesterday. I think she will miss the heat here. She seems to quite enjoy 90+ degrees.

________________________

For the Ragtag Daily Prompt: done.

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Choose the best

If you are going to have a knee replacement , you would try to choose the best surgeon, wouldn’t you? Yes. I am thinking of this because there is an illness where people often refuse the best. Not once but over and over.

I receive a card in clinic, a few days after a rather difficult day. Initially I don’t want to open it because it could be a yelling at me or threatening card. Hand delivered to our front desk. I open it and the card says what great care I give.

Wonderful, right? Except that there is a letter too, asking for a refill.

Most refills come through the pharmacy. Why a card and a letter? Have you guessed yet?

I call my patient. The patient was referred to the best addiction specialist in the area. The patient is not going to go to the specialist. The patient is not going to go to the group therapy, inpatient or outpatient. They can do this alone.

I let them know that I am not the local expert. I fail to change their mind. Yes, I will do a refill, but if they won’t see the expert, they have to come see me. Regularly.

This is typical for addiction. Denial and charm. A sweet card but trying to obscure that the patient is not going with the best treatment. I think of it as the drug or alcohol stil in control and whispering to the person: you are not really addicted, you don’t need anyone else, you can do it by yourself, we got this.

Chance of relapse? Well. I pretty much expect it. I would see this person monthly at least.

In what other illness do we refuse the expert, refuse help, refuse the best and say, I can do it alone?

For the Ragtag Daily Prompt: best: https://ragtagcommunity.wordpress.com/2025/06/29/rdp-sunday-best/.

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Hormones and rabbit holes

Medicine is confusing right now. Ok, it is always confusing because we try to base it on science and science is always changing. There are always special areas that are currently a mess. Hormones!

I speak to a patient recently who is female, premenopausal, and is getting hormone replacement therapy for hot flushes and not sleeping well from an outside source. The person wants me to order hormone tests. I do order hormone tests but not the ones she has in mind. I test a TSH, thyroid stimulating hormone, to see if she is low or high in thyroid.

She is thinking of me testing estrogen and progesterone and other related hormone levels. The party line from gynecology MDs and DOs is that these are not useful tests because women’s hormone levels are so varible. However, there are lots of naturopaths out there and functional medicine MDs and DOs who will test levels. Why is the patient asking ME to test them? Most of those naturopaths and functional medicine providers do not take insurance and charge cash. Also, insurance may not pay for them anyhow because the party line is that they aren’t useful. Why would the cash providers check levels? One reason is CASH. Another is to prescribe “bioequivalent hormone replacement”. Sounds natural, right? Well, the natural thing was for the hormones to stop at menopause and all of the hormones are either made in a laboratory from plant pre-estrogens or from pregnant mare urine, so bioequivalent seems to imply natural but it really isn’t. Pills do not grow on trees, they are made by humans in laboratories.

However, I question party lines, and off I go down the hormone rabbit hole. The current guidelines are that female hormone replacement, after menopause, should be lowest dose possible and only for a maximum of three years because of the increased risk of breast cancer. This doesn’t address my question: does premenopausal hormone replacement count as part of those three years? I may need to ask gynecology. I don’t think it counts. A woman is postmenopausal when she has had no periods for a year. Or had her ovaries removed. Or if she’s had a hysterectomy and still has her ovaries, a yearly follicle stimulating hormone and lutienizing hormone test. Both tests rise when the ovaries stop making hormones and eggs.

Also, there is another caveat. We know that when men are on opioids, the opioids can suppress their hormones and lower testosterone. Here is a paper: https://pubmed.ncbi.nlm.nih.gov/31511863/. Half the men studied in multiple studies had low testosterone when on chronic opioid therapy. 18429 subjects (patients) in 52 studies. That is a lot. Women studied? NONE. What? Yeah, none. Why? Here is part of the answer: about a decade ago I worked with the UW Telepain group and asked the head of the UW Pain clinic a question. “If opioids lower hormones in men, do they in women too?”

His reply, “I don’t know.”

“Have you ever tested a woman?”

“No.”

“Isn’t that sort of sexist?”

“Yes.”

So here I am, rechecking a decade later, and we still don’t know if giving women chronic opioids messes up their hormone levels. It would be more complicated and difficult to check women. We might have to do individual hormone baselines or something in premenopausal ones, say, 2 weeks after menses. Remember that for most of the history of medicine, clinical drug trials were only done in men, because, well, sexism. They said women could get pregnant. Yes, but then we gave the drugs to women who could get pregnant. Also, postmenopausal women can’t get pregnant. The whole thing seems stupid to me.

There is an interesting new finding here: https://neurosciencenews.com/estrogen-t-cells-pain-28548/ . Apparently in women, estrogen and progesterone work on receptors at the base of the spine to reduce pain signals using T cells, part of the immune system. The article says this doesn’t happen in men, but they were studying mice. The male mice didn’t seem to have worse pain after estrogen and progesterone were blocked. The female mice were in more pain. But wait, estrogen and progesterone are produced in men as a by product of making testosterone. Less than women, until menopause. Then the 70 year old man has more estrogen and progesterone than his postmenopausal wife. The article says that they don’t know why the receptors are in women and female mice (um, my intuitive guess would be childbirth and micebirth, right? Men don’t do that and women giving birth to a child after the first one sometimes say, “WHY did I want to do THIS again?” I think those receptors are so that women and mice can get through more than one pregnancy.) Now I need to read the article again because maybe men and male mice don’t have the receptors, even though they do have some estrogen and progesterone. Maybe they just don’t have enough estrogen and progesterone.

Maybe we can’t figure out women’s hormone because men aren’t smart enough, heh, heh. Yes, that is sexist right back at all those historical figures who didn’t study women.

At any rate, that still doesn’t answer my two questions: does premenopausal hormone replacement count towards the three year total beyond which hormone replacement increases the risk of breast cancer? And does chronic opioid treatment lower women’s hormone levels?

_________________

For the Ragtag Daily Prompt: hormone.

I took the photograph of a Port Townsend rabbit in 2011.

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Alcohol myths

I am back working in Colorado and a recurring theme this month is alcohol and alcohol myths.

Myth: If I only drink on my days off, I am not an alcoholic. Nope. People can binge one day a week and still be an alcoholic. A standard “dose” of alcohol is 12 ounces of 5% beer, 5 ounces of standard wine or 1.5 ounces of liquor. But what if someone drinks 8% beer, 12 ounces? Well, that’s 1.6 standard drinks. An 8% 16 ounce beer? That is 1.6 times 1.3, so 2.08 drinks. Perhaps we should have an app that calculates this. And locks the car ignition when we are over the limit.

How much alcohol means that we are an alcoholic? The guidelines right now in the US say 7 drinks per week maximum for women, 14 for men, no more than one in 24 hours for women, no more than 2 in 24 hours for men and no saving it up for the weekend. Here: https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/basics-defining-how-much-alcohol-too-much#pub-toc3. However, alcohol is bad for the liver, bad for the heart, bad for the brain, and increases cancer risk. There is not a “safe” amount.

What is binging or heavy drinking? For womenβ€”4 or more drinks on any day or 8 or more per week, For menβ€”5 or more drinks on any day or 15 or more per week. The rate at which people drink is also part of this.

MYTH: If I don’t throw up, I’m not an alcoholic. Now that’s an interesting one. When we drink, alcohol is absorbed into the blood and goes through the liver. The liver has enzymes which break alcohol down into aldehyde. Aldehyde is a carcinogen, causes cancer. Aldehyde is broken down by other enzymes into acetate and then to carbon dioxide and water. Some people break down the aldehyde quickly, fast metabolizers. They can drink a lot and not throw up because they break the aldehyde down fast. However, the process inflames and kills liver cells. If they keep drinking, the liver slowly dies, and this is cirrhosis. Eventually they will not be able to break down alcohol fast because the liver makes the enzymes. Then they will start throwing up.

Other people make enzymes that are slower or make less, and they get sick and have alcohol poisoning more quickly. The fast metabolizers are at higher risk for cirrhosis and the slow ones for liver cancer, but they can get either.

MYTH: “My blood pressure is fine.” I spoke to a person who stated that their blood pressure was ok during pregnancy so they did not have high blood pressure. The chart shows very high blood pressure for the last three years and I didn’t look back further. I ask, “Did you stop drinking alcohol while pregnant?” “Of course.” When NOT pregnant, this person admits to 4-5 drinks a day. Also, the history in the chart states that they had blood pressure complications in pregnancy. I did not have time to go through the chart and look at that, but this person is in denial. I think of denial as the addiction taking over and the addiction lies. It lies to me but it also lies to the person. They want to believe what they say. They want everyone else to believe what they say even if it is patently a lie and ridiculous. A woman who says a friend gave her something, she didn’t know what it was, for a headache. “How did you take it?” I asked, looking at the urine dip results. “I snorted it.” “So what things do you snort for a headache?” She was positive for cocaine and pleading ignorance was ludicrous. Another person has a positive urine drug screen for multiple things. “Can I try again?” Pause. “Sure.” I say. The first one is a false sample and I am very curious to see what the real sample will have. It has nothing. He is then surprised that I won’t fill his prescription and offer inpatient drug rehabilitation. Come now, sir, you got a urine sample from a dealer when you sold the medicine I gave you for something else. Your dealer must have been annoyed or gave you the wrong sample. When someone is really out of control, they do not have convincing lies and the only person they can convince is themselves. It is interesting to watch someone be all outraged that I do not buy the story, accusing me of discrimination or hating them or hating their race or whatever. They attempt to accuse and distract. It is harder for families because they desperately want to believe their loved one, even when the evidence shouts the opposite.

What does blood pressure have to do with alcohol? Alcohol drives blood pressure up and pulse, especially when it is wearing off. Severe alcohol withdrawal is delerium tremens and people can have such high blood pressure that they have a stroke or a heart attack or encephalopathy — a poisoned brain. They can hallucinate or have seizures and it is very dangerous. “Very dangerous” means they could die or have permanent disability. Tobacco, cocaine, methamphetamines, all raise blood pressure. The number one cause of death in the United States is the heart, but it’s not just from hypertension and weight and cholesterol and inactivity. Addictive drugs have a huge contribution.

There is nothing cheap about the cost of addiction in our country.

For the Ragtag Daily Prompt: cheap.

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Friends forever no matter what

My small child self is happy
Happy inside
She loves who she loves
Living or dead
In contact or fled
Distant or close
She loves who she loves
And I hold her close

My adult self is happy
Happy inside
I love who I love
And the world is so wide
Living or dead
In contact or fled
Loving forever
No matter what happens
I love who I love
My heart holds them close

My small child grieved losses
I hold her close
She loves them all
I guard her from most
She stays friends forever
No matter the grief
She is happy in loving
Her loves shine as stars
The ones who are hurtful
Are loved from afar
She’s held and she’s loved
And her love sings unmarred

_______________________________________

For the Ragtag Daily Prompt: dogwood and for Mother’s Day. Mine died 25 years ago.

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If eggs aren’t available, why can we still buy chicken?

I note this article this week: https://apnews.com/article/usda-firings-doge-bird-flu-trump-fdd6495cbe44c96d471ae8c6cf4dd0a8. That version says that the Trump Administration is trying to rehire bird flu experts that got fired. Most of the news outlets frame it differently: https://www.nbcnews.com/politics/doge/usda-accidentally-fired-officials-bird-flu-rehire-rcna192716. Suddenly it is the USDA at fault not the Trump administration’s chainsaw fool.

Should we worry about bird flu? Oh, yes, I think so. I have been wondering why we still have chicken to eat and chicken in the stores, if millions of chickens are being wiped out to try to prevent H5N1 bird influenza from moving into humans. This article explains in unreassuring detail how factory farms, packing chickens together, and killing them at 6 weeks old for meat, puts pressure on the virus to become more deadly and kill the host. In wild birds the influenza virus wants to spread, so it’s better not to kill the host fast. That is not true on our national and international big factory farms.

The Unnatural History of Bird Flu

Firing the people working the track the H5N1 bird influenza and trying to stop it if it starts going human to human, well. Is that injustice or arrogance or stupidity? Or all three? And who wants to work for the government now? It is being treated as a corporation, but it isn’t a corporation. Public service often pays less. Good luck hiring the best and brightest who want to serve our country and humanity.

This is the worst year in the US for influenza since 2017-2018 so far. That is without the H5N1 bird influenza really getting in to people. Here is the graph for the week ending February 15th from the CDC. I keep an eye on it all through influenza season.

The article on H5N1 bird influenza is the best argument I’ve ever read for choosing not to eat meat. I like meat, but the factory farming is going to more countries. It may produce more eggs and more chickens, but if it is also the perfect breeding ground for lethal influenza, that changes my viewpoint. We cannot go on. We will have another pandemic.

Why are humans such fools?

For the Ragtag Daily Prompt: injustice.

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New scar and whale songs

My receptionist of 6 years at Quimper Family Medicine, Pat McKinney, died on February 6th. The photograph is from October, when I was in Port Townsend again for two weeks. She and I went for a walk. Well, I was walking and she was in a wheelchair. She was in hospice for over a year.

We had fun working together. Pat played music at her desk because the patient rooms were not quite sound proof enough. One day she was playing whale songs. I hear her on the phone with a patient. “The noise? Those are whale songs.” Pause. “Oh, Dr. Ottaway insists on whale songs.” I started laughing, because she was the one that picked them. So much for MY reputation.

When the covid vaccine came out, I got mine as a first responder. A few days later we had a lull between patients. I was standing in the hall near Pat’s desk. I said, “I don’t know why people are fussing about the vaccine, it seems fine to me,” and I gave a big twitch. Pat started laughing. I could set her off all day by twitching at her.

Patricia McKinney, 2/17/1943 – 2/5/2025.

For the Ragtag Daily Prompt scars.

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Ice climb

Friday afternoon I drive to Ouray, Colorado, to meet a friend from high school. She has been ice climbing for years! I plan to watch, because ice climbing sounds terrifying. But I do take my harness, just in case. My friend talks me into trying it. The picture is NOT me. That is a competitor and she is amazing!

My climb was at the beginner ice wall. There are volunteers with loaner gear from gear companies. Boots, crampons, two ice axes and a helmet. My friend and a friend of hers give me instructions and I watch my friend climb first. She will be climbing all week!

I am wearing 1980s snow pants. Puffy and unstylish, but very very warm! I got all the way up and acquitted myself decently! Kicking each foot into the ice and then trusting that it will hold me, that is the interesting bit. Heel down, so that the crampon, boot and foot become a lever. And all the time in the climbing gym helped me to trust the harness, trust the ice axes, trust my feet.

For the Ragtag Daily Prompt: lever.