Tag Archives: rural doctor

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rural doctoring

I read Grampa’s Solo Visits this am and it makes me laugh.

Since I have been a family doctor in my town of 9000 for 22 years, the grocery store and coffee shops can be interesting. When I moved here, my daughter was two and my son was seven. We have three grocery stores. I usually go to the one 7 blocks from my house. I would see patients. My diabetics would sometimes look guilty and scurry away when they saw me. Another patient comes to peer in my cart.

“I want to know if YOU are eating healthy food.” he says.

I laugh.

“I don’t see any vegetables.” he says.

“I am in a CSA,” I say. “I get a box from the farm once a week.”

He frowns. “Do you get to choose?”

“No,” I say. “But since I hate throwing vegetables out, we eat more vegetables. Also, we eat ones that are unfamiliar. The first time I got celery root, I had to look it up. I didn’t know what it was.”

He nods. “Hmmm. Ok. We want to be sure you practice what you preach.”

I laugh again. “I sneak in to get the ice cream at midnight, ok? And where is YOUR cart?”

“My wife has it,” he says. “You don’t get to see it.”

“Ok, then. Have a great day.”

When we were first in town, occasionally someone would come start talking about their health in a store.

“I can’t discuss your health in front of my children. HIPAA.”

“Oh,” they’d say, “Uh, yeah. I should call the clinic Monday?”

“Yes, please.”

We had a coffee shop that made the best pastries that I’ve had since I was an exchange student in Denmark. I wished they’d make tiny pastries, bite size, for the diabetic folks. Those folks would slide a newspaper over their plate when I walked in with my family. They looked terribly guilty. I might nod, but I wouldn’t say anything. Sometimes they would confess at the next visit.

There are lots of jobs in small towns where people are very much public figures. Not just doctors, but the people who work for the city and the county, the ones who redo the taxes for homes, the realtors, all sorts.

After I was divorced, another doc at the hospital asks, “Dating someone new?”

I frown, “How do you know?”

She grins, “He lives on my street. I saw you.”

Dang it. The rumor mill is very very efficient and can often be fabulously wrong. That time it was correct, though I don’t think she passed it around. Other people live on the street.

A few days ago someone that looked familiar walks by me. “What are you doing with so-and-so?”

I laugh. “Rumors abound.” I say. “You would not believe the rumors!”

I took the photograph of the coyote yesterday, driving home. Stopped dead in my lane, no one else on the road. People will be stopped in the road here, talking to each other in two cars going opposite directions, or talking to a friend on foot.

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behavioral health, cancer, and the immune system

There are more and more articles about immune causes of “behavioral health” diagnoses.

The latest I’ve read is about schizophrenia:

https://www.nature.com/articles/s41598-020-63776-0

Auto-antibodies are antibodies that we make against something else that then attack a part of ourselves. The most well know version of an auto-antibody is Rheumatic Fever, where an antibody to streptococcus A attacks the joints or skin or heart. I had a patient in Colorado who needed a new heart valve at age 10 or 11 because of Rheumatic Fever.

I have written a lot about PANDAS and PANS (respectively Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep A and Pediatric Acute Neuropsychiatric Syndrome) because an older psychiatrist was suspicious that I have PANS. I have had pneumonia four times and it is accompanied by anxiety and fear, part of which turns out to be hypoxia and tachycardia. I think a heart rate of 135 makes just about ANYONE feel anxious. It feels awful.

But what about other Behavioral Health Diagnoses? Remember, we are on the DSM V, the fifth manual of psychiatric diagnoses. We have not had markers or a clear cause. That is, we are aware that serotonin is low in the intracellular spaces in the brain with depression but we don’t know what the mechanism is, what the cause is and what exactly is happening in the neuron or brain cells. A paper on a particular rat neuron said that there were 300 different types of serotonin receptors on that neuron. Blocking one type caused rats to act in an obsessive compulsive manner. But there are 299 others and then combinations. Whew, there is a lot to be learned about the brain.

Fibromyalgia can be caused by autoantibodies, at least some of the cases: https://www.sciencedaily.com/releases/2021/07/210701120703.htm

Chronic fatigue: https://pubmed.ncbi.nlm.nih.gov/34441971/

Lupus and fibromyalgia overlap: https://pubmed.ncbi.nlm.nih.gov/9207710/

Autoimmune disorders are more common in women. We think this is because of pregnancy. The woman’s immune system has to tolerate a pregnancy where half the genetic material is from the father. Yet the immune system also has to recognize “not me, infection” and be able to distinguish that from the pregnancy. This is tricky. The most common autoimmune disorder currently is believed to be Hashimoto’s Thyroiditis, where there are self antibodies to the thyroid. Post covid could potentially beat this out.

Chronic fatigue and fibromyalgia have been orphan diseases in that we do not have an inflammation marker that defines them. The ESR (erythrocyte sedimentation rate) and CRP (um) are usually normal. These are often elevated in rheumatological disorders. Not having a marker doesn’t mean that the muscles are not painful and doesn’t mean that the fatigue is not real.

I am hopeful that we are on the cusp of a true revolution in medicine, with more understanding of the immune system and behavioral health disorders, as well as post covid, fibromyalgia and chronic fatigue. I worked at the National Cancer Institute in the 1980s before medical school, with Steve Rosenberg, MD. He was trying to get the immune system to fight cancer.

Now there has been a cancer treatment with 100% success: an immune treatment for people with rectal cancer with a particular immune profile. This is AMAZING! https://www.zmescience.com/science/experimental-trial-cancer-complete-remission-02725735/

Only 18 patients, but 100% success! No surgery.

The patch for the National Cancer Institute shows a man fighting a crab: Cancer, the crab. Dr. Rosenberg talked about Sysiphus, who was rolling a stone up a mountain eternally while it rolled back on him. From here: Later legend related that when Death came to fetch him, Sisyphus chained Death up so that no one died. Finally, Ares came to aid Death, and Sisyphus had to submit. In the meantime, Sisyphus had told his wife, Merope, not to perform the usual sacrifices and to leave his body unburied. Thus, when he reached the underworld, he was permitted to return to punish her for the omission. Once back at home, Sisyphus continued to live to a ripe old age before dying a second time.

Maybe the stone has reached a resting place. Blessings and peace you. Please peace me.

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failure of the medical non-system

One thing that makes me gloomy, as a Family Practice Physician: the only person who has read my medical notes from the multiple specialists is ME.

Since March 2021, I have seen Family Practice, Cardiology, Pulmonology, Infectious Disease, Immunology and Psychiatry. I am in a rural area, so this involves three different hospital systems. They all use the EPIC electronic medical record, but they won’t release information to each other. I have gotten two of them hooked together under ONE of my names and passwords but guess what: my primary care physicain can’t see the notes from the other sites. Only I can. “Proprietary infromation.” Hey, you stupid medical non-systems, this is MY healthcare, MY notes, and YOU SUCK.

My primary care physician COULD request the notes from my pulmonologist but she hasn’t. I find this incomprehensible. I have been on oxygen for over a year. I guess my doctor frankly doesn’t care. Has she farmed my lungs out to pulmonology and doesn’t have to pay attention any more? My goal in practice was to have all of the specialists’ notes. If that was five different specialists, I requested them. Ok, it is next to impossible to get psychiatry notes. I keep wondering if psychiatrists really write notes. The patients never seem to know what diagnosis the psychiatrist is using. One hundred percent of the people that I have seen put on an (addictive) benzodiazepine say that it is for sleep. Meanwhile, at the conferences, the psychiatrists say that primary care should not give the patients benzodiazepines for sleep. I raise my hand: “Even when you psychiatrists have started them? The patients all say it’s for sleep. We don’t know WHAT you have them on it for.” When I try to stop the benzo, the patient has a fit and says that psychiatry said they have to have it. And the psychiatrist has retired or left or changed the phone number and there are no notes ever.

Anyhow, I am counting up specialists. I had really bad strep A pneumonia in 2012 and 2014. Since 2012 I have seen 20 specialists. That is counting the three Family Practitioners, because Family Practice is a specialty too. I thought it was about taking care of the whole person, which to me means reading all the specialists notes, but not one of the ones I have been to has done that.

So the medical system is an abject failure. I blame the US citizens. We choose the system with our votes. We need medicare for all, single payer healthcare, and one electronic medical record for all of the United States. Right now, there is a push to privatize medicare and turn it over to For Profit. We need to fight this and we need to demand better healthcare. Hospital organizations should not be refusing to send my clinic note to my primary care doctor. It is stupid and bad care.

https://pnhp.org/ Physicians for a National Healthcare Program for more information.


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how doctors think, a dual pathway

A friend calls today and says that another person is bleeding and yet they have been set up to be seen Monday. Why isn’t this an emergency?

Based on the limited information the friend tells me, I agree with the doctors. It is NOT an emergency and I explain why. It is uncomfortable for the person because it may be cancer. Why is that not an emergency?

Let’s use chest pain in the emergency room as an example. Doctors have two brain tracks that are triggered simultaneously by every patient. The first one is “What could kill this person in the next five minutes?” The second is “What is common?” Common things are common and more likely. In medical school the really rare things are nicknamed zebras. You know there are a lot of horses but you can’t miss the zebra. I suppose that in Africa the common things are zebras and the rare ones are orcas or something like that.

Anyhow, the killers for chest pain are heart attacks, sudden death. But there could also be a dissecting aortic aneurysm, where the largest artery in the body is tearing. That person can bleed to death really really fast and that is a surgical emergency. No doctor wants to miss it. There could be a pulmonary embolism, a clot blocking the lung. Chest pain could be from a cancer. A very rare chest pain is from the valve leaflets in the heart tearing so that the person goes in to flash pulmonary edema. And there is Takayasu’s Arteritis, “broken heart syndrome”, where the heart suddenly balloons in size and again, heart failure ensues. Heart failure is actually pump failure, so fluid backs up in the lungs or the legs or both. It is usually slow but rarely very fast and dramatic. A collapsed lung can also cause a lot of pain. And my list is still not complete, I haven’t mentioned pericarditis or myocarditis or a compression fracture.

The common things do include heart attacks, but also anxiety, musculoskeletal problems, inflamed cartilage of the chest wall, fibromyalgia flares, broken ribs, trauma and other things. I was very puzzled in clinic by a woman with pain on both sides of her lower chest wall. In front but cutting through her chest. I ruled out many things. I thought that it was her diaphragm. I sent her to a rehab doctor for help. The rehab doctor sent her to radiology. She had a compression fracture of her spine and the nerves were sending pain messages on both sides. That was not even on my “differential diagnosis” list, because she had no back pain at all. My list changed that day.

Physicians and nurse practitioners and physicians assistants and registered nurses and licensed practical nurses and medical assistants are all trained to think of this differential diagnosis. We are alerted by the history and have to think down both pathways. Last year working as a temporary doctor, the medical assistant came to me saying, “This patient’s blood pressure is 80/60.” “Is he conscious?” I asked, as I went straight for the room. “Yes, he’s talking.” He WAS talking, which means that he’s gotten to 80/60 slowly or is used to it. His heart rate was fast, up near 120. I immediately had him drink water and keep drinking, as soon as he denied chest pain. The problem was dehydration: he was developmentally delayed and had only had one cup of fluid that day and it was now midafternoon. I spent time explaining that he needed 8 cups each day. Not more than that, because if he had too much fluid, it would lower his sodium and make his muscles weak. Most days he drank 3-4 cups. His chart graphed the problem: some days he had normal blood pressure and a normal heart rate. Other days his blood pressure was below normal and his heart rate was fast, his heart trying to make up for the low level of fluid. Cars don’t do so well when there is almost no oil, do they? His kidneys were affected as well. I asked him to drink the 8 cups a day, discussed the size of the cup (not 8 gallons, please) and then recheck labs in 2 weeks. If his kidneys did not improve, he would need a kidney specialist. It turned out that he had nearly fainted that morning in the waiting room. His group home person admitted that no one had noticed that he really was not drinking fluid. I thought that the patient understood and would try to drink a better amount of fluid.

So back to the person I was called about. Infection has been ruled out. This is blood in the urine. A kidney stone has been ruled out, but there is something in the kidney. This is urgent, but if the person is not bleeding hard, it is not emergent. When there is blood in the urine it does not take very much to turn it red. If there is a lot of blood, that can be an emergency, but from the story I got third person, it’s not very much. The emergency things are ruled out but there is still not a clear diagnosis. Yes, cancer is one of the possibilities but it could also be benign. Now a specialist is needed to figure out the next step and the differential diagnosis, the list of things it could be. They will order tests in the same dual order: what could kill this person quickly and what do we need to rule out as common? People often can be very anxious during this period, which is normal. The person says, “I don’t care what it ISN’T, I want to know what it IS.” But sometimes it is a zebra and it takes a while to get to that specific test.

Another example is a woman that I sent to the eye doctor. The optometrist thought it was something rare and bad. He sent her to the opthamologist, who ruled out the first thing, but thought it was something else rare and bad. He sent her to a retinal specialist. The retinal specialist ruled out the second rare and bad thing and said, “No, you have something very rare that is benign.” My patient said, “I have three diagnoses. Who do I believe?” I replied, “No, you have one. The optometrist knew it was unusual and sent you to an eye doctor. The eye doctor know it was unusual and sent you to an even more specialized eye doctor (a “sub specialist”. We keep them in basements.) Now you have a diagnosis. It was a scary process, but I think you should focus on the third opinion because hey, she said it’s benign and it won’t hurt you! That is the best outcome!” She thought about it and agreed. The process was frightening but the conclusion could not have been better.

For the Ragtag Daily Prompt: disquieting.

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Patient Satisfaction Score

The latest issue of Family Practice Medicine has an article on patient satisfaction scores.

I remember my first patient satisfaction score VIVIDLY.

I am in my first family medicine job in Alamosa, Colorado. I receive a 21 page handout with multiple graphs about my patient satisfaction scores. I am horrified because I score 30% overall. I am more horrified by the score than the information that I will not receive the bonus.

I go to my PA (physician’s assistant). He too has scored 30%. We are clearly complete failures as medical providers.

Then I go to my partner who has been there for over 20 years.

She snorts. “Look at the number of patients.”

“What?” I say. I look.

My score is based on interviews with three patients. Yes, you read that correctly. THREE PEOPLE.

And I have 21 pages of graphs in color based on three people.

I am annoyed and creative. I talk to the Physicians Assistant and we plan. I call the CFO.

“My PA and I think we should resign.”

“What? Why?”

“We scored 30% on the patient satisfaction. We have never scored that low on anything in our lives before. We are failures as medical people. We are going to go work for the post office.”

“NO! It’s not that important! It is only three patients! You are not failures!”

“Three patients?” I ask.

“Yes, just three.”

“And you based a bonus on three patients? And sent me 21 pages of colored graphs based on three patients?”

“Um…”

“I think we should discuss the bonus further….”

I did not get the bonus. It was a total set up and I am not sure that ANYONE got that bonus. Much of the maximum “earning potential” advertised was impossible for any one person to get. You would have to work around the clock. They got out of paying us by having multiple bonuses that each required a lot of extra work…. They were experts in cheating the employed physicians. That became pretty clear and I was 5th senior physician out of 15 in two years, because ten physicians got right out of there. I lasted three years, barely. I knew I would not last when an excellent partner refused her second year of $50,000 in federal rural underserved loan repayment to quit AND stayed in the Valley working in the emergency room. I called the CEO: “Doesn’t this get your attention?”

“She just didn’t fit in.”

“Yes, well, I don’t think anyone will.” I asked my senior partner how she stayed. “You pick your turf and you guard it!” said my partner. I thought, you know, I hope that medicine is not that grim everywhere.

Unfortunately I think that it IS that grim and getting grimmer. Remember that in the end, it is we the people who vote who control the US medical system. If we vote to privatize Medicare, we will destroy it. Right now 1 in 5 doctors and 1 in 4 nurses want to leave medicine. Covid-19 has accelerated the destruction of the US medical non-system, as my fellow Mad as Hell Doctor calls it. We need Medicare for all, a shut down of US health insurance companies, and to have money going to healthcare rather than to paying employees $100,000 or more per year to try to get prior authorizations from over 500 different insurance companies all with different rules, multiple insurance plans and different computer websites. Right now I have specialists in four different local systems. The only person who has read everyone’s clinic notes is ME because it is nearly impossible to get them to communicate with each other. Two of them use the EPIC electronic medical record but consider the patient information “proprietary” and I have to call to get them to release the notes to each other. Is this something that we think helps people’s health? I don’t think so. I have trouble with the system in spite of being a physician and I HATE going to my local healthcare organization. Vote the system down and tell your congresspeople that you too want Medicare For All and single payer.

Physicians for a National Healthcare Program: https://pnhp.org/

Healthcare Now: https://www.healthcare-now.org/

I have had people say, but think of all the people out of work when we shut down insurance companies. Yes AND think of the freedom to start small businesses if we no longer have to fear the huge cost of insurance: Medicare for all!

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Microbiome Dating Service

You have been perfecting your health for years.

You know the antiaging regime and you follow it religiously.

You have read Jeffrey Bland. You have been tested for the mthfr mutation. You understand pandas. You have taken a functional medicine class and you’ve studied biochemistry in your local functional medicine group. You have reversed your autoimmune symptoms by a combination of the best from Dr. Ballantyne and Dr. Perlmutter. Your adrenal fatigue is gone. You have the pajamas that Dr. Oz says help most with sleep. You know your supplements backwards and forwards and have visited the clean green factories that make them.

You are healthy.

You are ready for the perfect relationship. But…. would you want to date someone who doesn’t take care of themselves? What if they don’t care? What if their bacteria invade YOU?

WELCOME TO THE MICROBIOME DATING SERVICE!

We will remove your fears and cares. All clients agree to a monthly detailed microbiome stool screen. You will date healthy people. If a screen fails, a client is notified and all dating partners are notified as well. Clients agree to EXCLUSIVE DATING with other healthy people, tested and monitored.

You are healthy. You want to stay that way. WELCOME TO THE MICROBIOME DATING SERVICE!

WE KEEP YOU SAFE.


http://www.nytimes.com/2013/05/19/magazine/say-hello-to-the-100-trillion-bacteria-that-make-up-your-microbiome.html?_r=1

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Update on whatever it is I have

I had the heart echocardiogram bubble study. Normal. I really really did not like having the mix of blood, saline and AIR injected and I COULD FEEL IT. My logical brain knew it was going into a vein, but my emotional brain kept yelling “Air embolisms kill people!” Yes, but that is arterial. My emotional brain did not care. Anyhow, it was fine.

Saw the cardiologist who said he can understand why I feel PTSD going into my local hospital. He says I should not need oxygen at age 60 with no smoking. He says “Not your heart.” Yeah, duuuude, I know. He suggests I go to the Mayo Clinic. I agree.

Meanwhile, my primary sent a referral to rheumatology to have me seen at Swedish to confirm chronic fatigue. This is to keep the stupid disability off my back. Swedish rheum doesn’t call me. I ask my primary’s office. Swedish STILL doesn’t call me. I call them, as follows.

“Hi, I was referred to Swedish rheum and I have not been called.”

“Name, serial number, date of birth, length of little toe. Ah, we just received the referral yesterday.”

“Um, I don’t think so. I was referred over a month ago.”

“Uh, oh,” scrabble noises, “Oh, uh, we got a referral in December. We were not taking new patients in December.”

“When did you start taking new patients?”

“Oh, um.”

“When did you start taking new patients?”

“Oh, uh, January. But we only took the ones that called us, because after they call, we then review the notes.”

“So you ignored the referral until I call? How am I supposed to know that?”

“Oh, uh, we will expedite your referral. Maybe even today.”

So THEN I get a message from my primary that they have REFUSED the referral. Great.

Meanwhile I read the cardiologist’s note, which pisses me off. “We will refer you to Mayo Clinic since you have unexplained hypoxia and you think you have PANS.”

I send my primary a very pissed off note saying, could we please phrase this as “a psychiatrist suggested PANS in 2012 and while no one likes this diagnosis, no one else has suggested an overarching diagnosis since that time in spite of her seeing four pulmonologists, neurology, cardiology, infectious disease, four psychiatrists, allergy/asthma, and immunology”. Saying “the patient thinks she has PANS” automatically labels me as crazy and obsessed.

So, it seems I should write a book, about how the medical communities treat patients, including a fellow physician, horribly. Of those doctors, three have treated me with respect and were grown up enough to say, “We don’t know.” The neurologist, the infectious disease doc and the present pulmonologist. All the rest are dismissive and disrespectful. Oh, and the one psychiatrist, but the next one says, “I don’t believe in PANDAS.” I stare at him in disbelief, thinking “they are animals related to raccoons that live in China, you moron”. I did not even know it was controversial until that moment. Holy PANDAS, Batman.

My primary has suggested I write to the Mayo Clinic myself, and I am going to. Because the present people aren’t listening, except my pulmonologist and she is short staffed and looks like death warmed over post call every time I see her.

So it’s all annoying as hell. The cardiologist seemed pretty nice, but damn, he put the same damn rumor down about me self diagnosing. Most of the doctors apparently think I might be a tolerable person if they could just drug me with psych drugs. And from what I have seen, there are many patients who are in this situation.

For the Ragtag Daily Prompt: WAR.

https://pubmed.ncbi.nlm.nih.gov/30724577/

Click to access MECFS_KeyFacts.pdf

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mad skills

What are your mad skills?

My maddest baddest skill, shared with my younger sister, is reading hidden emotions. Children of alcoholics and addicts learn that one young. Or die. Or start drinking/drugging to numb young.

Our culture is bloody weird. Emotions are stuffed like turkeys until people are near bursting. I swear that half my clinic time was letting people talk about emotions and then saying, well, those seem like pretty reasonable feelings in view of the insanity going on in your family. There would be a silence while the person thought about the horrible terrible feelings being reasonable and then I would say, “You said you want an antidepressant. Do you want to discuss that?”

Often people put it off. Once the feelings are OUT and present and looked at instead of stuffed/contained/terrifying, the person would say, “I don’t know. I don’t know if I need it.”

“Do you want to schedule to come back in two weeks?”

Sometimes yes, sometimes no. If they wanted to start an antidepressant, I would caution that the recommendation was to stay on it for six months minimum if tolerated. Also, if they were starting it in June, I would say, “Don’t stop it in January. Wait until the sun is back. Here that can be July 4th. At least wait until spring.”

The plants are all thinking about spring now. My magnolia would like three more days of sun and then it will burst into bloom. The plums are budding and close to exploding. My camellia is usually first, but I trimmed it at the wrong time of year and so it is not blooming. It looks healthy, though. It is sort of sulking for a season. I would like to sulk for a season too.

Why is our culture, the US, so terrified of emotion? We think everything should be about logic. Emotions are both hormonally and electrically mediated through nerves and blood and they are INFORMATION about our environment and each other. We should let emotions roll through us like waves, and not worry about them so much. I think of myself as an ocean. The emotions are the weather. They roll through. Ok, big storm. Then rain, and lightening. Then low clouds and some fog. Then sun and a beautiful day to sail with a light breeze. But the deeper currents change slowly and the weather is not really that important. I reside in the depths.

The furor over rising prices seems ridiculous to me. The roaring twenties has begun already in housing and buying stuff on Amazon. I have bought two things from Amazon in the last two years. I like to buy local. One order was for my future daughter in law’s wish list. I think people are buying so that they do not have to feel. It is cultural mania. Everyone is rushing around trying to make money instead of grieving. Yesterday I thought, if this keeps up, we WILL have a depression like 1929.

Don’t do it. Don’t buy stuff to avoid the stuff inside. Sit still twice a day, for at least five minutes, and just listen. Try to listen to the depths.

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hope for good coming out of isolation

This video is from 2011. I was invited to be a speaker and had ten minutes to present the Mad as Hell Doctor program, talking about single payer healthcare, medicare for all.

If there is a good thing to get from Covid-19, for me it is single payer healthcare. Because doctors and nurses and staff are worn out, sick, quitting, dying. We need people to take out sick appendixes. We need people to work in nursing homes. We need to support our medical people and I am NOT talking about insurance corporations. They are making more profit than ever. Twenty percent of every dollar paid to them or more.

People say, but it’s socialized medicine, to have medicare for all. Well, no. The only socialized medicine in the US currently is the Veterans Administration. No one that I talk to wants to take away Veterans benefits. Or any of the other government programs: medicare, medicaid, active duty military. The oldest, the poorest and disabled and the people defending our country.

But physicians can do a better job if they are not worrying about prior authorization from 500 + companies, each with multiple different insurance contracts, and who can change what they cover at any time. I get emails all the time: we have changed what we cover. Great. Like I have time to read and learn 500+ insurance contracts. I memorize medicare rules and they change too. Medicare for all, one set of rules and then if you ask if something is covered, we will know.

I am not the only physician who wants single payer: Physicians for a National Healthcare Program.

Physicians for a National Health Program

I find this on line: https://www.quora.com/Could-Medicare-or-Medicaid-be-expanded-to-the-general-population-to-create-single-payer-healthcare-Would-it-be-more-efficient-than-an-entirely-new-program?share=1

The answer is yes, yes, yes. And there would be a continuous ongoing battle about what is covered and what isn’t but that already happens. For two reasons: medicine changes continuously as the science changes and there is a vocal strong fringe, which is occasionally correct. I don’t trust the fringe, but then I don’t trust insurance companies, herbal medicine makers or politicians either.

_____________________________

I can’t credit the videographer because I did not know that the video was being taken or that it was posted. I found out when a new patient said she was seeing me because of my video. I had to look it up.

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Covid-19: Long Haul

https://www.bbc.com/news/av/world-us-canada-58918869 Some people with Long Haul Covid-19 are having to relearn how to walk and talk.

https://www.bbc.com/news/uk-england-leicestershire-59674203. Patients who were hospitalized are still affected at 5 months and one year after they are released from the hospital. Being female and obese are big risk factors. The article says “Long Covid has the potential to become highly prevalent as a new long-term condition.”

One more:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8146298/ ” While the precise definition of long COVID may be lacking, the most common symptoms reported in many studies are fatigue and dyspnoea that last for months after acute COVID-19. Other persistent symptoms may include cognitive and mental impairments, chest and joint pains, palpitations, myalgia, smell and taste dysfunctions, cough, headache, and gastrointestinal and cardiac issues.”
“One puzzling feature of long COVID is that it affects survivors of COVID-19 at all disease severity. Studies have discovered that long COVID affects even mild-to-moderate cases and younger adults who did not require respiratory support or hospital or intensive care. Patients who were no longer positive for SARS-CoV-2 and discharged from the hospital, as well as outpatients, can also develop long COVID [24,30,31,41,50]. More concerningly, long COVID also targets children, including those who had asymptomatic COVID-19, resulting in symptoms such as dyspnoea, fatigue, myalgia, cognitive impairments, headache, palpitations, and chest pain that last for at least 6 months [51–53].”

And the symptoms? “The most common ongoing symptoms were fatigue, muscle pain, physically slowing down, poor sleep and breathlessness.”

Yes, the same as mine.

My initial evaluation of Long Haul Covid-19 patients will cover three areas:

1. Behavioral Health. Are they having brain fog, feeling slowed, feeling like they can’t think? Is that what happened during the Covid-19 or did the opposite happen? Were they manic/ADHD/OCD etc? What happened in the weeks leading up to getting sick? Any major worries or life trauma? Lose a job, a relationship, someone in the family die? I am looking for a dopamine antibody pattern.

2. Musculoskeletal Chronic Fatigue. What muscles work and which muscles don’t work? If they need to lie in bed for 20 hours a day, both slow and fast twitch muscles are affected. If they are short of breath, they should have pulmonary function tests, including a loaded and unloaded walk test. Are their oxygen saturations dropping? They also need a sleep study. Check for sleep apnea. Any signs of ongoing infection with anything? Teeth, sinuses, ears, throat, lungs, stomach, lower gut, urinary, skin.

3. Musculoskeletal Fibromyalgia. WHEN do their muscles hurt? Is it after eating? Do they fall asleep after they eat or does their blood pressure drop after eating? What diet changes have they made? Are there things they have identified that they can’t eat? Gluten, lactose, meat, sucrose, fructose, nightshades, whatever. I am looking for antibodies to lysogangliosides.

Treatment:

High antibody levels can be lowered somewhat just with “lifestyle changes” aka no drugs.

A. Treat infection if present. Look for strep A with an ASO, since we have an occult one that is in the lungs, not the throat. For fungal infection, even just on the skin, lower blood sugar as much as tolerated. This may mean a ketotic diet.

B. Treat behavioral health with drugs if emergent. If suicidal or really losing it (meaning job/relationships/whatever), then drugs may be needed. But not forever. Avoid benzodiazepines. Check for addictions.

C. Lower antibody levels:
a. Lower stress. Many people will resist this. Counseling highly recommended, ‘cept they are all swamped. Have the person draw the three circles: a day in the present life, their ideal life and then what their body wants. Listen to the body.

b. You can sweat antibodies out: hot baths, hot shower, steam room, sauna, exercise. Daily in the morning, because cortisol rises when we get up, and so levels should be lowered.

c. Is there a stimulant that works for this person to calm them down? Or an antidepressant if they are slowed instead of sped up. The relatives of dopamine that work for ME are coffee caffeine and terbutaline. Ones that do NOT work for me include albuterol and tea caffeine. Ones that I have not tried include theophylline, that new relative of albuterol and ADHD meds like adderall. This will be individual to the person because we all make different antibodies. We are looking for a drug that displaces the dopamine antibodies. For people who are slowed or have brain fog, the stimulants may not work. I would try the SSRI antidepressants first, like sertraline and citalopram, unless the patient tells me they don’t work or make them anxious. I would screen for PTSD. For high PTSD scores and high ACE scores, I would use the old tricyclics, mirtazapine (which is NOT a benzodiazepine), wellbutrin or trazodone. Again, avoid benzodiazepines. Also check how much alcohol and marijuana are on board, because those are definitely going to make brain fog worse. The functional medicine people are treating mystery patients with hyperbaric oxygen chambers and I suspect that this works for the people with blocker tubulin antibodies.

d. Muscle pain/fibromyalgia symptoms. Avoid opioids, they will only work temporarily and may addict. Avoid muscle relaxants, they will only work temporarily. Again, the tricyclics may help. The newer antiseizure drugs that are indicated for fibromyalgia are possibilities, though as an “old” doctor I am conservative about “new” drugs. Gabapentin, pregabalin, and if the person is sped up, antiseizure medicines that are used for mania. GENTLE exercise. The line between me having a good day today and overdoing is knife thin. On the overdoing days I go to bed at 5 pm. I went to sleep at 5 pm yesterday and 6:30 last night. I sang for church last night and even though I’d driven myself there, one of the quartet offered to drive me home. “Do I look that grey?” I asked. “Yes.” he said. I turn grey from fatigue and it can be sudden. Right now it’s after my second meal. If I am active, I will fall asleep after lunch if I can. If I go really light on lunch, I crash right after dinner. And remember, I am one of the lucky people who only have fast twitch muscles affected, not fast and slow twitch.

I am adding this to yesterday’s Ragtag Daily Prompt: hopeful.