Thoughts on Ramadan

I have been thinking about Ramadan.

Those religions. Judaism, where you don’t eat pork or shellfish. We do know the reasons: trichanosis and food poisoning. And possibly that paralytic shellfish disease: that would be bad, right? People die fast. So pork and shellfish are forbidden.

But Ramadan. I have thought about it for a long time. I think I will do it next year, the diet part. Because I think I have been doing it: in 2012 and 2014 and now. I change my diet to help kill whatever bacteria I have. I go ketotic and the bacteria that require sugar or glucose or fructose can’t grow. It kills them. Quite effectively, since I was sent home after 24 hours of hospital observation when I had strep A pneumonia and sepsis in 2012, after drinking only 4 liters of fluid and putting out ten liters of urine. This is not a good thing. If it goes on, my circulation would collapse, which happens to be the defining symptom of sepsis. Since I did not want my circulation to collapse, I drank 6 liters of water when I got home. With electrolytes and MgS04 because I had a very low potassium and magnesium when I hit the ER. The hosptialist just said that I was bananas in her discharge summary, but she failed to explain the potassium and magnesium and she didn’t even LOOK at the nurses record of the oral intake and urine output. This is not my standard of care. I think one should ALWAYS look at the test results. The usual urine output is up to 2 liters. Ten liters should have stopped her dead in her tracks. Unfortunately I think she had me labeled. Bananas or not, a crazy person can ALSO get pneumonia and sepsis. Really.

She did give me a penicillin shot. Unfortunately it was the dose for strep throat. Not very much penicillin. After I failed to improve from the antibiotics for a couple of days, I thought OH. THERE ARE TONS MORE BACTERIA WHEN IT IS A SYSTEMIC INFECTION. INADEQUATE ANTIBIOTICS. I pulled my sanford guide. For strep A sepsis you are supposed to treat with:

penicillin G 5 million units iv every 6 hours

and clindamycin 3 million units iv every 6 hours. At least, that was the treatment in 2012.

Damn, I thought. Bit hard to do that at home on my own, isn’t it? Now what?

So I called a local pharmacy. I ordered penicillin V 500mg one four times a day and clindamycin 300mg four times a day and then I hunkered down and ate NO CARBOHYDRATES for two weeks.

Penicillin tablets are horse pills and bitter. Yet the first one I put in my mouth, it tasted delicious. Super weird. But my body must have been saying THANK YOU THANK PENICILLIN and released a crazy high dose of dopamine in my brain.

After two weeks I hoped the damn strep would be dead. I took myself out to dinner, feeling like shit, and ordered food. It tasted like heaven, but…..sepsis symptoms once my blood sugar went up. Third spacing fluid. It feels like sand running out of an hourglass as the fluid leaves your arteries and veins. It also causes an instant and terrifying panic attack as your body tries to tell you YOU ARE ABOUT TO DIE GET FLUID HELP HELP HELP.

Which is why sepsis can get misdiagnosed as a panic attack or mania or what the fungk ever. It is by miles one of the most terrifying things I have ever been through.

Survived it. At home. While my fellow docs in my small town whispered about how I was bipolar. A physician’s assistant told me that the internist told her at a party that I am bipolar. Ok, I cried again. He sucks. How the hell does he know? He’s not my doctor.

Another woman doctor said, “I heard about you in a meeting. After all we aren’t really friends.” I didn’t say much. Afterwards I stared at the phone. I thought we were friends. Guess not. And ok, speaking of HIPAA, what the fungk did they say about me in a hospital meeting? Fungk them. Over and over and over, please. Spank them with a HIPAA paddle.

Next I read about strep A sepsis. Gosh, once you get it you are more likely to get it again. Damn. Power of suggestion. I got it again one year to the day from when I found my father dead in his house. Stress, you see. He’d left an out of date will, my sister was dead of cancer, it was written when I was nineteen. I knew what my father wanted. He’d said that I was the only person he know who could handle my sister, so I was the person he wanted to watch over her daughter. But the damn will didn’t SAY that.

So I did what any sensible human would do. I took the stupid will to an attorney and did what he said. So then the interfering family sued the executor (me) on my niece’s behalf. Stupid interfering mean and actually not very bright family. After three rounds, I said give it to her.

Half the estate? said my attorney.

Yes.

But… how do you feel about that?

It’s good for me. I will be done with her and that part of the family. It’s not what my father wanted but my niece clearly doesn’t want me to watch over her. Ok, fine. Give her the money. Never mind that her mother extracted at least 1/3 of the estate before my father died and made him cry. I was pretty pissed at my sister for making our father cry. That is when my father and I started comparing notes on what my sister was doing. It was grim. Anyhow, let the dead lie. Sometimes they do when they are alive, too.

It’s not good for the niece. Handing her that stack of money is thoroughly dangerous. And she’s over 18, so, well. It is on my cousins’ heads, whatever happens.

Long silence. My attorney says: you are a really nice person.

Well? I said. Have you known any cases like this.

Yes, he said reluctantly. A 19 year old. He got half a million dollars. He was dead in five years.

Mmmm hmmm. I said. Well, I wish her the best.

Anyhow, second round of strep A sepsis/pneumonia. And third round of pneumonia. With the hospital physicians for the most part still insisting that I was a liar. I mostly handled it at home though I confess that when I started bleeding from my gums, I got scared and went in. The kale water, vitamin K source, kicked in and it stopped by the time I got there. The ER doctor said that he wouldn’t believe me unless the disseminated intravascular coagulopathy labs were high. They were only a little high, but he broke his word, told me I was nuts and sent me home. He also told me I was dehydrated, which was comic because I’d asked the nurses for a “hat” and urinated 4 liters while I was in the emergency room. I was keeping track. I WOULD have been dehydrated except that I was drinking fluid when he was not looking. My daughter brought in a water bottle and quietly went to fill it. I didn’t trust that moron ER doctor to take care of me if my blood pressure tanked. Stupid man.

Home again home again.

This time they don’t believe me again. This time I think it’s funny. Also I caught it early enough so that I don’t have sepsis, praise to (your deity of choice)! I have been here for 21 years, doing medicine in this town. I was one of the two doctors who took the lead in the opioid overuse crisis. The hospital didn’t break down and train its doctors until 8 years after I started. You’d think they might say, wait, she has weird ideas….. but you know, sometimes they are really GOOD weird ideas.

Back to Ramadan. I think spending a month being ketotic and only drinking water during the day has a purpose. I think that it kills bacteria that require sugar, and also yeast and fungi, and possibly some viruses, too. What is the mechanism for the virus killing? Well, the cells slow their metabolism in ketosis, because the lizard brain thinks that the person is starving. Some systems get shut down, like chronic pain. Acute pain is still on line because WE HAVE TO FIND FOOD. In ketosis, the body burns fat and protein to make just enough glucose to keep the brain alive, and the side product is ketones. If it is the body’s store of fat and protein, well, that is starving, right? The lizard brain can’t tell if it’s an outside source. FIND FOOD so vision is sharper, hearing is more acute. Fast twitch muscles burn too many calories, so they are decreased. The slow twitch are ON so that we can go for miles and miles if need, cross continents… and where did I learn all this? Not from medical school or residency. There was a brilliant article in the Atlantic Monthly, about fasting for over a month to lose weight. He wrote about the history of fasting and fear of it and about… ketosis. Thank you, Atlantic Monthly, your article helped save my life when my doctors would not listen and sent me home to die.

Maybe viruses can’t get into the cell as easily when the cells slow their metabolism. Or, better hypothesis, the cells are slower so they don’t make viruses very well. They are slow. They ought to ride the short bus.

Ramadan 2022 starts April 1, 2022 and ends May 1, 2022.

I think I will start three days early, on March 29. Because I want to end early. Because… something big is happening at the end of that April in 2022.

Blessings.

biotics explained

Are you confused about BIOTICS? Is your neighbor taking more Mysterious Healthy Pills than you? We can help! We are marketers posing as scientists from Mega Super Good For You and the Planet CoreValuePoration! Look! We have white coats and ours are clean!

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Conbiotics: These are BAD FOR YOU! They are sold by the other companies. They lie. They get biotics from prisoners poop. They will turn you criminal. They will make you fight with your mother and disinherit your first born, lie, drink too much and cook meth. You will know they are conbiotics because they are cheaper and not refrigerated. And some of the biotics in their tablets are bacteria! Do you want to take bacteria? DEAD BACTERIA, they don’t even give you live ones.

Antibiotics: THESE KILL PROBIOTICS. BY THE MILLIONS. THESE ARE PASSE, OUT OF FASHION, EVIL AND YOU REALLY DON’T WANT THEM (unless you have strep throat or pneumonia or sepsis, and even then, the antibiotics suck because the sepsis mortality rate is 28-50%, THAT MEANS HALF THE SEPSIS VICTIMS DIE EVEN WITH ANTIBIOTICS, DOES THAT PROVE THEY SUCK OR WHAT?)

UNCLEBIOTICS: Now MEGA SUPER GOOD FOR YOU AND THE PLANET COREVALUEPORATION is developing THE NEWEST AND BEST BIOTICS OF ALL! UNCLEBIOTICS ARE BETTER THAN ANTIBIOTICS BECAUSE THEY ARE MALE AND UNCLES ARE MORE FUN AND RARER THAN AUNTS AND THEY ARE WAY LESS LIKELY TO HUG YOU INTO WEIRD SMELLING BOSOMS, except that uncle that wears the boa and the weight lifter uncle, too many illegal steroids, he has fine manboobs.

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Why is she really here?

For the Ragtag Daily Prompt: object. I strenuously and loudly object to medicine meaning pills.

During my three months temp job at a nearby Army Hospital in 2010, I wanted to work with residents, Family Practice doctors in training. I finished residency in 1996 and have worked in rural clinics and hospitals for 14 years. I want more rural family practice doctors and I agitated to work with the residents in training.

The Family Practice Department had actually hired me to do clinic. They are swamped and trying to hire temporary and permanent providers as quickly as they can. Six different temp companies called me about the same job, so the word is definitely out.

Initially the department head explained that I was there to do clinic, but she changed her mind. I was cheerful about the electronic medical records. Learning a new electronic medical record is awful, but I was happy to be there, excited about working with residents and in a hospital more than 16 times as big as my usual small town hospital. Most importantly, I was patient with the computer. I have finally realized that computers don’t actually speak English. They speak computer and they are dumb as rocks and they make no effort to understand what I am saying. They don’t care. So it is no use getting mad at the dumb thing when it crashes or when it doesn’t do what I want: I have to go find someone who knows the exact language that the stupid machine will understand.

Since I was cheerful, my department head let me do what I want. I was on the clinic schedule every day, but it was empty. I would arrive and see walk-in active duty people from 6:30 to 8:00. At the same time, I would email the department head and ask what I was doing that day. Half the time, a physician was sick or had a family crisis, so she would move people around and put me with the residents. If not, I would open clinic.

I enjoyed the “Attending Room” duty. Family Practice Residents have their MD but then go through three years of training. The first year residents must precept every clinic patient. That is, they see the person and then come discuss the case with the faculty. Second year residents were required to precept two patients per half day and third year residents had to do one; and all obstetric cases were precepted.

Back when I was in residency and the dinosaurs roamed the earth, no one ever read any of my notes. This has changed. Every note that is precepted must be read by the attending and co-signed. After three years hating the electronic medical record that my small hospital bought, it was very interesting to see a different system. In some ways it was better and in some worse.

We had one or two “Attendings” in the faculty room, no more than three residents per attending. One case stands out, more because of the resident than the patient. He was a first year.

He described an elderly woman in her 80s, there for headaches. Two weeks of headaches, getting a bit worse. History of present illness, past medical history, medicines, allergies, family history, social history and the physical exam. He said, “She’s tried tylonol and ibuprofen, but they aren’t helping that much.” He frowned. “She doesn’t seem to want another medicine.”

“No?” I said.

“No.” he said. “I started to talk about medicines. It doesn’t sound like migraines and she doesn’t have anything that’s really worrisome for a tumor……but she doesn’t seem to want a headache medicine.”

“Why is she really here?”

He looked more confused. “What do you mean?”

“Why is she really here?”

“I don’t know.”

“You already said why. Think about the history.” He frowned. I said, “Ok, you said that she was worried that she was going to have a stroke. Are these headaches likely to be a precursor of a stroke?”

“No.”

“Right. But that is why she’s here, because that is what she’s worried about. Look at her blood pressure, see what her last cholesterol was, talk to her about what symptoms ARE worrisome for strokes. Find out if a family member or friend has had a recent stroke. She doesn’t need a medicine. She is here for reassurance.”

“Oh.” he said. He left and came back.

“How did it go?”

“She was happy. She didn’t want a medicine. Her blood pressure is great, her cholesterol is great, we talked about strokes and she left.”

“That’s real medicine. Forget the diagnosis if the visit seems confusing. Ask yourself what is your patient worried about? What are they afraid of? Don’t focus on giving people medicine all the time. Ask yourself, why are they really here?”

And that is why I wanted to work with residents. It’s not all diagnosis and treatment. It is people and thinking about what they want and what they are worried about.

Why is she really here?

__________________________________

previously published on everything2.com
According to dictionary.com, precept is a noun. Medical school and residency have verbed it. Hey, get updated, dictionary.com!

appropriation

From the Centrum Voiceworks conference, Reverend Robert B Jones, Sr’s hands and guitar. Previous post about him here.

He was teaching blues history class in the morning and gospel in the afternoon, linked. One person asks about cultural appropriation. The Reverend says that he thinks songs and history are important. He asked if there are songs that he should not sing because they are “white” songs. He says there ARE songs that he WON’T sing because they are racist or sexist. But that if a white person does not sing a song because it’s “black”, he doesn’t think that makes any sense. And he traces history in his classes of how musicians of many races and genders influenced each other and continue to influence each other.

He and other instructors talk about musical skills and guitar and acoustic instrument skills and singing styles that are being forgotten and lost. We are blessed with recordings and he gave us a four page list of people to listen to…. I knew some, Bessie Smith and Robert Johnson, and others I’ve heard of and others I don’t know at all. Homework for the next year!

Blessings on this day for you and everyone, all the world.

More Dawn

Here is one of the Voiceworks Classes with Dawn Pemberton. My biggest problem is I want to go to all five or six classes that are running simultaneously and then there are people playing music in the halls, on the porch, singing in the practice rooms!

And we’re on our feet practicing singing soul.

DSCN3532

Make America sick again: diabetes

The trend in diabetes treatment is clear: keep Americans sick.

The guidelines say that as soon as we diagnose type II diabetes, we should start a medicine. Usually metformin.

A recent study says that teaching patients to use a glucometer and to check home blood sugars is useless. The key word here is teach, because when I get a diabetic transferring into my clinic, the vast majority have not been taught much of anything.

What is the goal for your blood sugar? They don’t know.

What is normal fasting? What is normal after you eat? What is the difference between checking in the morning and when should you check it after a meal? What is a carbohydrate? What is basic carbohydrate counting?

I think that the real problem is that the US medical system assumes that patients are stupid and doesn’t even attempt to teach them. And patients just give up.

New patient recently, diabetes diagnosed four years ago, on metformin for two years, and has no idea what the normal ranges of fasting and postprandial (after eating) are. Has never had a glucometer.

When I have a new type II diabetic, I call them. I schedule a visit.

At the visit I draw a diagram. Normal fasting glucose is 70-100. Borderline 110 to 125. Two measurements fasting over 125 means diabetes.

After eating: normal is 70-140. Borderline 140-200. Over 200 means diabetes.

Some researchers are calling Alzheimer’s “Type IV diabetes”. The evidence is saying that a glucose over 155 causes damage: to eyes, brain, kidneys, small vessels and peripheral nerves.

Ok, so: what is the goal? To have blood sugars mostly under 155. That isn’t rocket science. People understand that.

Next I talk about carbohydrates. Carbohydrates are any food that isn’t fat or protein. Carbohydrates range from simple sugars: glucose and fructose, to long chain complicated sugars. Whole fruits and vegetables have longer chain carbohydrates, are absorbed slowly, the body breaks them down slowly and the blood sugar rises more slowly. Eat green, yellow, orange vegetables. A big apple is 30 grams of carbohydrate, a small one is 15, more or less. A tablespoon of sugar is 15 grams too. A coke has 30 grams and a Starbuck’s 12 ounce mocha has 62. DO NOT DRINK SWEETENED DRINKS THEY ARE EVIL AND TOOLS OF THE DEVIL. The evidence is saying that the fake sugars cause diabetes too.

Meals: half the small plate should be green, yellow or orange vegetables. A deck of card size “white” food: grains, potatoes, pasta, whole wheat bread, a roll, whatever. A deck of card size protein. Beans and rice, yes, but not too much rice.

For most diabetics, they get 3 meals and 3 snacks a day. A meal can have up to 30 grams of carbohydrate and the snacks, 15 grams.

Next I tell them to get a glucometer. Check with their pharmacy first. The expensive part is the testing strips, so find the cheapest brand. We have a pharmacy that will give the person a glucometer and the strips for it are around 4 for a dollar. Many machines have strips that cost over a dollar each.

I set the patient up with the diabetic educator. The insurance will usually cover classes with the educator and the nutritionist but only in the first year after diagnosis. So don’t put it off.

For type II diabetes, the insurance will usually only cover once a day glucose testing. So alternate. Test 3 days fasting. Test 1-2 hours after a meal on the other days. Test after a meal that you think is “good”. Also after a meal that you think is “bad”. I have had long term diabetics come in and say gleefully “I found a dessert that I can eat!” The numbers are not always what people expect. And there are sneaky sources of carbohydrate. Coffeemate and the coffee flavorings, oooo, those are REALLY BAD.

For most of my patients, the motivated ones, they have played with the glucometer for at least a week by the time they see the diabetic educator. I have had a person whose glucose was at 350 in the glucose testing. The diabetic educator called and scolded me for not starting metformin yet. The diabetic educator called me again a week later. “The patient brought their blood sugars down!” she said. “She’s under 200 after eating now! Maybe she doesn’t need the metformin, not yet!” Ah, that is my thought. If we don’t give people information and a tool to track themselves, then why would they bother? They eat the dessert and figure that the medicine will fix it or they can always get more medicine.

Type I diabetes has to have insulin. If a type II diabetic is out of control, high sugars, for long enough, they too will need insulin. The cells in the pancreas that make insulin are killed by prolonged high blood sugars.

I went to a lunch conference, paid for by a pharmaceutical company, at the AAFP conference in September. The drug company said start people on metformin at diagnosis and if they are not in control in 3 months, start a second medicine, the drug company’s new and improved and better and beastly expensive medicine!!!

Yeah, I don’t think so. All of my patients are smart and they all can figure it out. Some get discouraged and some are already on insulin, but they are still all smart.

Fight back against the moronization of US citizens. Keep America healthy, wealthy and wise.