speaking up

A friend says he does whatever he wants. He refuses to answer questions about how he makes his money. He doesn’t care if this annoys people. I suspect he may enjoy it.

I have one of those public jobs. Well, had. I have now been disabled from Family Medicine for a year. My lungs are much better than a year ago but they are not normal. And I have now seen 17 specialists and 3 primary care doctors since 2012. The consensus is “We don’t know.” Though many specialists are not willing to say that. What they say instead is, MY testing is NORMAL, go to someone else. My lungs are not normal, but I am on my fourth pulmonologist. I saw a cardiologist this year and the first thing he says is, “It’s your lungs, not your heart.” Well, yeah, I know that.

I miss my patients, but there is something freeing about not working. Ok, more money would be nice, but I am doing ok. Meanwhile, I am thinking about what to do now. I can write full time. Write, make music, travel (on a budget) and sing. And speak up.

Doctors have interesting portrayals on television. We went from Dr. Kildare to Dr. House, working our way through the shows with an emergency room and medical residents. ER drove me nuts. No one EVER dictated a chart so at the end of each show I hyperventilated at the hours of paperwork/computer/dictating they had left. House interests me because it’s always the thing that the patient is hiding or lying about that is the key. “Go search his apartment.” says House. I have figured out cases by getting permission to call family or a group home. More than once.

But a physician is a public figure. I had been here for less than a year when a woman comes up to me in the grocery store and says “What are my lab results?” I look at her blankly. I can’t remember if I really did the snappy comeback that comes to mind: “Take off your clothes and I will see if I remember.” I respond politely and she says, “Oh. I should call the office, right?” “Yes, I try to leave the work there,” I say. If a particularly difficult person was bearing down on me, I would whisper “cry” to my kids. That worked. They would act out on cue and I would be the harassed mother. The person would back off.

I am in a small town. We have three grocery stores. I see patients everywhere, now that it has been 22 years. If I remember every detail, that means they are or were really sick. And we have the layers of relationships: someone might have kids the same age or work with boats or be in chorus with me. Once I take my daughter to a party. The mom introduces me to two other mothers. “She’s my doctor,” says the introducing mom. “Well, me too.” says the second. “And me,” says the third. We all laugh.

Once I am visiting my brother outlaw’s bicycle shop. He has a customer. The customer starts talking to me too. Brother outlaw says, “Do you two know each other?” The customer eyes me. I have my neutral doc face on. “She’s seen me NAKED!” says the customer and I howl with laughter. What a great reply. And my brother outlaw gets it.

Docs have to pay attention to HIPAA. When three women say that I am their doctor, I reply, “Yeah and I left my brain at work, so I can’t remember a thing.” Those three were healthy, so I really do not remember labs or the results of a pap smear. Once I was in cut off shorts and waved at an older woman who was at the ophthalmologist’s. She sniffs and looks away. I get the giggles: I think she did not recognize me. My town is only 10,000 people, so after 22 years I have taken care of many of them. Though sometimes people thank me for taking care of their mother, and after it sounds unfamiliar I ask if they mean Dr. Parkman? Oh. Yes. People get me mixed up with two other small Caucasian woman doctors.

I started the “outfits inappropriate for work” category last year when I was still very sick and short of breath and on oxygen. I did not go out much, partly to avoid covid. My pneumonia was something other than covid and it was my fourth pneumonia and I should not need oxygen. Now I’ve had mild covid and the oxygen is only part time. I sang at my son’s wedding, off oxygen, so I can sing off oxygen for a short time. I danced off oxygen too and did get QUITE short of breath. Since I am no longer a public figure, I can speak out and speak up more. I am thinking about that, particularly with the recent Supreme Court news. I do not agree with what they seem to be planning.

Covert covid conundrum

I had covid recently AND I have been very lucky with it.

WHAT?

Ok, so when the war started I had been talking to a friend in Europe about visiting. He said nice seasons were May and September, but he and his wife have a kitchen make over planned for September.

“My son is getting married at the end of April, after two year long postponements, and so May doesn’t seem feasible. Maybe next May.”

Then the war starts. And it is affecting gasoline and causing inflation. I call my friend. “Can I come in two weeks?” March to early April.

“Yes. We have other guests a week after that.”

“Ok.” I try to get a British Airways ticket to stop in London to see an old friend from high school. British Airways has a computer attack and three days go by. To heck with it. I buy a ticket to Paris and on to my friend’s country.

I spend an hour on the phone trying to change to a layover in Paris for three days. I manage that. I fly to Paris and then take the train to London. Three wonderful days with my friend in London. I mask on planes, metros and trains. I double mask on the airplane, with my oxygen, and use a ceramic straw to drink liquids.

After three days I take the train back to Paris, the local train to the airport, and fly to my old friend’s. I arrive at midnight and we take the metro.

We do lots of sightseeing and take a memory trip to his parents’ graves and the town we lived in when I was 17 and he was 18.5. I was an exchange student. The language comes back. I can read but listening is more difficult. My brain won’t process it fast enough.

Four days before I am due to fly back, I get an email from AirFrance. I need a negative PCR covid test within 24 hours of flying to return to the US.

Well. I have a mild headache and muscle aches. Probably not covid, BUT. I go online, register in the country for a test and go to the testing site. Positive. I read about covid. The muscle aches of this strain usually happen at day 4-5. I did notice that going from London to Paris to my destination four days earlier, I feel a little off balance. Not bad, not spinning, just slightly weird. So my guess is that I am at day 4 or 5 of covid.

My hosts have both had covid within the last month, so I am not confined to my room. I read the rules for being allowed on the airplane once you HAVE covid. I have to wait 11 days, have a certificate of the test and then the eleven day certificate saying cleared. I isolate for 5 days, spend about 8 hours rescheduling the flight with Air France and Delta, and contact my doctor. My doc wants me to take medicine, but the local medical people where I am say I am not sick enough. I agree with the local people. The headache is gone the next day, I have mild sniffles, and my lungs are fine. Well, at least, they are no worse.

When I am out of isolation, I take a train to another town masked and stay at a hotel for four days. In that country, 80% of the people are vaccinated and 80% have had covid. They are no longer masking, except a few. I am feeling good. I mask when I am around other people and in all public spaces in the hotel.

The trip home is rather more exciting than I would like. At the airport I am informed that I need a doctor clearance ALSO. They say retest. I say “I AM a doctor.” and pull out a copy of my license. I brought it just in case the war spread and I needed to help out. They let me on the plane. In Paris I nearly miss my connection, but am one of the last 8 people on the plane. I am very relieved once we take off.

The silver lining is that at my son’s wedding I am now very unlikely to get covid or give anyone covid and mine was very mild. The Omicron BA2.12.1 that is circulating in Europe is milder than the previous strains AND ten times more contagious or more. So the covid is morphing towards a cold, which is what coronaviruses used to do to us. There are some strains that I read about that are going in a more virulent direction, so I would prefer to have the mild one and be protected from the nasty ones.

Here is the CDC section about strains in the US:

https://covid.cdc.gov/covid-data-tracker/#variant-proportions

I arrive home on April 12 and then am unsurprised to see covid cases starting to rise again in the US. Here is the CDC tracker: https://covid.cdc.gov/covid-data-tracker/#datatracker-home

I am hoping that it’s more and more Omicron BA2.12.1, since it seems to be milder. I am reassured that covid did not make my lungs worse. Within a week I am better from covid and then get what seems like a normal cold. Covid testing negative. I am feeling well for the wedding and reassured that a normal cold does not force me on to continuous oxygen. I am feeling lucky about the version of covid that I have but I am NOT recommending that people get it on purpose, because even with mild covid, some people go on to develop long covid. Here is an article that I got yesterday through the American Academy of Family Practice:

https://www.healio.com/news/infectious-disease/20220425/global-prevalence-of-long-covid-substantial-researchers-say

Long covid is very worrisome and we don’t know what it will look like after a year or more. Many of the present studies are on unimmunized people, from the first year of covid, so the studies of immunized are still evolving. There is hope that there is less risk of long covid with immunization but there is still a risk.

Covid will continue to morph into different strains. We continue to get “colds” or “upper respiratory infections” because the viruses are very very good and fast at changing and avoiding our immune systems. Consider checking the CDC data tracker above regularly to see if your county or your destination has a high covid level and if so, mask back up.

One caveat: my local health department says we have a high level of transmission right now, here:

https://www.jeffersoncountypublichealth.org/1429/COVID-19

while the CDC says low, here:

Remember that all of these sites have to exchange data and update everything. My best guess is that the local has the best numbers, but that is a guess.

acoustic bicycle

Over KwanChunChrisSoliday, we discuss bicycles. We now have a plethora of electric bicycles, so we need a phrase that describes the “old” style bicycle. We came up with acoustic or analog. I like acoustic bicycle, because it sings.

My friend B-from-Arlington (BfA): “But they don’t make noise.” He didn’t approve of either idea.

“Well, we had spoke bells, and playing cards. My bikes make noise.” Sometimes it’s me making it.

We are riding on a rails to trails path in Northern Virginia. Seven of us and me on oxygen. It’s only my second bike ride since March 2021, when my lungs fell apart. We are all on acoustic bicycles.

I feel pretty strong for most of it, 14.5 miles. It seems flat, though it is a very gentle downgrade, until the last 0.5 mile, which is gently up hill. Oh, my lungs don’t like that bit at all and by now my muscles are saying Why are we doing this? I am relieved when we get to the coffee shop destination. Three of us will stay there, while the other four will ride back and get the cars. I hang out with K-f-A, BfA’s spouse, and their son. Their son examines my phone, asks why it has four camera eyes. I have no idea, so he proceeds to figure it out. We play with the slow motion camera for a while.

We know what a penny farthing is, and safety bicycles and tricycles. The early safety bicycles did not have brakes and had wooden rims and wooden spokes. My brother outlaw has one, from the 1880 or 90s. Another friend collects penny farthings and has one that is entirely of cast iron. It would be a little bumpy and the seat is pretty hard. It is also massively heavy. So now we add acoustic bicycles to the electric ones.

Go, google, spread the word.

________________________________

Dang, others have come up with it too. Traditional bicycle sounds too fogey.
https://www.reddit.com/r/ebikes/comments/hp2l30/can_we_please_stop_calling_traditional_bicycles/
https://www.bikebiz.com/what-shall-we-call-the-non-electrified-bicycle/

Covid-19: working in healthcare

So, should healthcare workers be required to have Covid-19 vaccines?

Yes.

What is the precedent?

Take tuberculosis, for example. Airborne, very contagious. I was born in a Knoxville, Tennessee tuberculosis sanatorium, because my mother coughed blood a month before she was due and got quarantined for active tuberculosis. Yes, the state could quarantine my mother. I was removed immediately at birth because tuberculosis doesn’t cross the placenta. The antibodies do, but the infection doesn’t. However, newborns usually catch it and die very quickly. I was lucky. My father and grandparents took care of me for 5 months. Then my mother was allowed out (after 6 months total) but was not strong enough to take care of me. So I was taken to my maternal grandparents for the next four months, and did not touch my mother until I was 9 months old.

My mother was taking 36 pills a day at home, because you have to use multiple drugs to kill tuberculosis. It develops drug resistance very very quickly.

Well, so what, you say?

Healthcare workers in the United States are routinely checked with a ppd for tuberculosis. If it is positive, you cannot work until further testing. If you have latent tuberculosis, you are treated. If you have active tuberculosis, the treatment is longer and more complicated, here: https://www.cdc.gov/tb/topic/infectioncontrol/default.htm

My cousin then said, “Well, you don’t have to show the tuberculosis test to go in a restaurant!”

Well, not right NOW, because currently tuberculosis is under more or less reasonable control in the US. Remember that guy who came in to the US with active multi drug resistant tuberculosis and knowingly exposed everyone on that airplane? Great. I remember reading about that and thinking what a selfish jerk he was. And then the group of unimmunized people who went to India and all got measles. The US at that time did not bar anyone from returning, but asked them to finish a 3 week quarentine before returning to the US. One person did not do that. There was a measles outbreak in the midwest which cost the CDC (and therefore you and me because those is tax dollars) millions to trace, quarantine and clean up. So there was discussion at that time about whether the policy should be changed and we should not allow US citizens with known infectious diseases to come in on airplanes. We DON’T allow immigrants in with infectious diseases: they are tested for tuberculosis if coming from countries where it is endemic.

So, if we had a huge outbreak of tuberculosis, we WOULD have quarantines and shut downs.

I have tested a patient for tuberculosis, about two years ago. Her son had been diagnosed with active tuberculosis. We tested her with a blood test and then repeated it in three months. Negative, hooray. In residency I also saw a case of miliary tuberculosis. That is where the tuberculosis is growing so well in the lungs that it looks like little grains of rice in the lungs on imaging. Not a good thing.

My cousin: “You shouldn’t have to put something in your body to work.”

If you have tuberculosis, you do not get to work in healthcare, because you can kill your patients. I think that this is a good thing, to not kill our patients.

I am submitting this to the Ragtag Daily Prompt: starspangled. Keep America Healthy, how about that?

plane view

I took this last month when I flew to Michigan for an almost brother’s birthday. He turned 50. The rising sun was just amazing and I could see the mountains beautifully. Yesterday’s photograph was also from the plane. I flew from Seattle to Chicago. In Chicago I took a taxi to the train station. There I waited for a train for four hours and then rode up into Michigan. It was my first real journey with the oxygen concentrator. My carry on had the concentrator, three back up batteries, my camera, a laptop and phone and charging cords for all of them. A heavy bag and I had to pull out laptop, batteries and camera at security. Fun, eh? But I had enough oxygen for a 12 hour journey and could plug in on the train. I could have plugged in on the plane too, but the cord was in the overhead compartment. Anyhow, it worked. Oxygen tubing, N95 mask and second mask over the N95… whew.

I also learned that I need to let the airline know 48 hours in advance that I am traveling on oxygen. They tend to seat you by a window so no one trips over your tubing. Though I was in an aisle seat on the way back. Anyhow…. made it, hoorah!

Covid-19: simplified self care

  1. I am a Family Practice Physician for 30 years. I have had pneumonia four times. I last got pneumonia on March 20, 2021 and I am still off work and on oxygen. This is the first time I have been on oxygen. No tobacco, no marijuana, no lung disease found to date but my mother had tuberculosis when I was born and my father smoked unfiltered Camels. With the hospital beds filling up, this is to help keep people out of the emergency room if they don’t need to be there and to help people track how sick they are.
  2. Learn to take your pulse. You need a second hand. Your heart rate is the number of beats in 60 seconds. Take it at rest (which means sitting or lying down). Then try taking it after you walk. It should be regular unless you have known atrial fibrillation. Also, if you are fifty or older, you may skip some beats so that you have early or late ones. That is not worrisome.
  3. Normal is 60-100. If you are very out of shape, you might go up to 120 after you run up the stairs or walk fast.
  4. If your resting pulse is 120 or higher, call your physician. If you are very short of breath with that or your lips are turning blue, call an ambulance right away.
  5. If your resting pulse is normal, say, 70 beats per minute, and your pulse after walking goes up 30 points or over 100, you are sick. If you are very short of breath after walking you may need oxygen. Call your physician and walk… really… slowly. When your lungs are swollen, there is less air space to exchange oxygen and your heart makes up the difference. If your heart is beating at over 100 for long, it is like running a marathon. Don’t stop walking completely because you are at risk for blood clots. But walk really slowly.
  6. If your resting pulse is normal and your walking pulse is ok, try a loaded walk. Carry something that weighs 20 pounds if you can. Then sit down and check a pulse again. If it is over 100 or jumps 30 points, you too have lung swelling, it’s just a little more subtle. You need to rest too.
  7. With practice, you will have a good idea what your pulse is before you do a formal count.
  8. You can use a pulse oximeter but you have to use it accurately. The fingers should be not moving and lying on the person’s knee or table or something. Otherwise it will give inaccurate readings and scare you. With a regular heart rate, look for the light to be picking up regularly before you believe the oxygen level. O2 sats under 87% need oxygen, but also if someone is going below 95% or is a child, call doctor or ambulance.
  9. Take a multivitamin. It is a lot of work for your heart to race fast. Rest, rest, rest. I have had 4 rounds of pneumonia with lung swelling. It took two months, two months, a year and this time I am five months post pneumonia and still on oxygen.
  10. Don’t use quack supplements and don’t take veterinarian ivermectin. Hello, you are not a sheep.
  11. Remember that if someone is hypoxic, they may act goofy, happy and unconcerned or be scared or have memory loss or just be confused. I write really weird rhyming songs when hypoxic and have the poor judgement to sing them to my doctor.
  12. GETTING VACCINATED IS YOUR BEST BET TO NOT DIE OF COVID-19. AND WEARING A MASK ALL THE TIME AROUND OTHER PEOPLE.

Good luck and take care.

Covid-19: caring for yourself

audio version, covid-19: Caring for yourself

A friend took his father to the ER in the next bigger town, sent there for admission to the hospital from the clinic. His father is in his 90s, has heart failure, and his legs were puffed up like balloons with weeping blisters.

They were in the ER for 13 hours, never given food though it was promised, the staff couldn’t even find time to bring a urinal and his father was not admitted. He was sent home. No beds. On divert.

Ok, so when should you go to the hospital right now? Only if you really really can’t breathe….

First, the emergencies. An ER nurse friend talks about “happy hypoxia” where people do not feel bad but have an oxygen saturation of 50%. I suspect that this is when their lungs really are swelling shut very fast. They will turn blue quickly. Call an ambulance. In the 1918-1919 influenza, soldiers “turned blue and fell over dead”. In Ralph Netter’s book on pulmonary diseases, he has a drawing of the lungs of a person who died from influenza pneumonia. The lungs are basically one big red purple bruise with no air spaces. So if a friend is goofy and their lips are turning blue: AMBULANCE.

The one in five hospitals that are 95% full or more in the US are now cancelling all of the elective surgeries: knee replacements, hip replacements, non emergent heart surgeries, all of it.

If you are not dying, do not go to the emergency room if you are in one of the totally swamped areas.

So how to care for yourself with covid-19? Like influenza, it is pretty clear that it either causes lung swelling or the lungs fill with fluid or both. With lung swelling you may be able to stay home. First take your pulse. If you have a pulse oximeter, great, but no worries if you don’t. .What is your resting heart rate? Count the number of heart beats in 60 seconds

If it’s 60-100, that is good. It’s normal. If it is 120 at rest, that is getting worrisome. If you are short of breath at rest and your pulse is over 100, call your doctor. If they can get you oxygen, you still may be able to stay home. If not, emergency room.

Now get up and walk. Do you get short of breath? Sit back down and again, count the number of heartbeats when you are sitting. If your resting pulse was 90 and you jump to 130 walking, you have lung swelling. Functionally you have half the normal air space and so your heart is making up the difference. How to cope? Well, walk slowly. Walk during the day, do get up because otherwise you may get a leg blood clot, but really minimize your activity. Now is not the time to rearrange the furniture. Also, you may not go to work until your walking or loaded pulse is under 100.

If your pulse does not jump up when you walk, next try walking loaded. That is, carry something. Two bags of groceries, a toddler, a pile of books. Go up the stairs. Sit down and take your pulse when you are short of breath or it feels like your heart has speeded up. I am in this category. My pulse is 70, oxygen at 99 sitting. Walking my pulse jumps to 99. Walking loaded my pulse goes to 125 and my oxygen level starts dropping, need oxygen once it gets to 87. I tried a beach walk without oxygen 3 weeks ago. I photographed the pulse ox when it was at 125 with O2 sat at 87. I still need oxygen.

The treatment for lung swelling is rest. This is my fourth time, so I am used to it. Some people will have so much swelling they will need oxygen at rest. If the lungs swell shut, they need to be intubated or they die. Suffocation is not fun. The other treatment is not to catch another virus or a bacteria on top of the present lung swelling. Wear mask, get vaccinated, put out the cigarrette, no vaping, pot is terrible for the lungs too and increases the risk of a heart attack.

With my four pneumonias, the first two made me tachycardic and it took two months for the lung swelling to subside. It sucked. Inhalers don’t work, because they work by bronchodilating. You can’t bronchodilate swollen lung tissue. The steroid inhalers might help a little but they didn’t help me. The third pneumonia took 6 months to get back to work and then I was half time for 6 months. This time I am five months out today and I still need oxygen. Darn. Don’t know if my lungs will fully recover. They may not.

So: rest. Good food. Avoid substance abuse. Mask all visitors and don’t go to parties/raves/concerts/anything. Oxygen if needed and if you can get it.

Take care.

The photograph is me wired up for a sleep study a week ago. The technician took it at my request. I won’t have results until next week.

On vaccination: rock stubborn

A friend in his 30s was working on my car the other day. “Are you immunized?” I ask. “No.” he says. “I wish you’d get immunized,” I say, “Also, I can’t ride in the car with you because if I get the Delta variant, I’ll probably die.” He responds, “I hate doing what other people tell me to do.” “Oh,” I say, “Oppositional defiant, just like me. Fine. Don’t get the vaccine.”

Two days later I text. “Don’t get the vaccine today. Or tomorrow.”

I hear back. He got vaccinated the day I sent the text. I don’t know if it was me saying don’t do it, or me getting out of the car and staying a good ten feet away after that. Please don’t kill me, not today, ok?

Maybe we should try it nation wide. “DON’T GET VACCINATED. DON’T DO IT TODAY. OR TOMORROW.”

Unvaccinated thirty year olds are getting really sick and getting intubated and dying. One in five hospitals in the US now is 95% full, on divert. I used to heave a sigh of relief when I was in residency and we were on divert. That meant no admissions until beds opened back up. We are full. But one in five is really bad. Virginia Mason in Seattle is on divert. Our rural county has more covid infections than we’ve had the whole time, mostly unvaccinated. About 15% vaccinated. We are starting to see the breakthrough infections, around 8 months after the vaccine. Makes sense, because the vaccine riles up the immune system for 8 months and then quiets down. I am 8 months out, no immune system, high bleeping risk. The head of the heart lung bypass part of Virgina Mason was interviewed. “We have been full for ten months (?or a year) and have turned away over 150 patients.” So heart lung bypass could save lives in covid. But it takes round the clock two ICU nurses and the ICU nurses are burning out, quitting, dying. If they get too tired, their immune systems don’t work, they are more at risk for covid and they could die. The nurses and the doctors KNOW this. So…. how many unimmunized people are you willing to die for? Just curious.

Kids have been at home, quarantined, small groups. So then they started school or daycare or even a few more playdates and hello: when you get them together, they trade viruses. There is an outbreak of RSV and other viruses. RSV won’t kill most kids but some babies need the hospital and it can kill premies. And the beds, remember, are full.

Now the AAFP is calling for emergency authorization for kids age 2-11 to get the vaccine. Because they are dying too and there bloody won’t be room in the hospitals at this rate. Or well, you can build a tent, but if you don’t have any ICU nurses, the tent is not too helpful.

For the governors saying “No mask mandate at school,” yeah, well, I think they should refuse the vaccine and refuse treatment and refuse intubation and refuse oxygen.

Meanwhile, I am hiding under the bed. Roll up the sidewalks, lock the doors, I am sorry not to be useful but I am not useful dead. I could telemedicine if our area gets shorthanded enough. I suppose I should call the hospital and say that. They aren’t that desperate… yet. We have four ventilators last I checked. And 32,000 people in the county and we are the only hospital. Bummer.

I am in a physician mothers Facebook group. The stories are getting grimmer and grimmer. A physician put up the list of hospitals she called to try to transfer a patient: over 30. All no. Another is in North Carolina and got a call from Texas to transfer a patient. But… they were on divert. No.

Take care. Don’t get your immunization if you are against it. Whatever.