Words behind my back
damaging
hurtful
gossip and lies
I forgive
I wait
I wait
I wait, wait, weight
Weighted 13 years For them to speak to me Instead of about me At last waiting makes me angry I have forgiven tried to connect some of them say they love me this is not love waiting weight of hurt and anger
And I let go
of the wait
of the weight
I forgive myself
I am free
I rise
I let them go
they are forgiven
but they may not enter my life
again
not ever
I forgive myself
I am free
I rise
unweighted
________________________
For the Ragtag Daily Prompts: weight and chopper. My heart is what is chopped, and the abandoning friends and family wielded the choppers.
People are ordering versions related to semaglutide (ozempic) and dulaglutide (trulicity) from compounding pharmacies for various reasons. Their insurance may not cover the prescription or they may actually not qualify by their weight and complications. Here are the guidelines from the American Gastroenterological Association: https://www.aafp.org/pubs/afp/issues/2023/1000/practice-guidelines-medications-weight-loss.html. Those criteria: a body mass index (BMI) greater than 30 kg per m2 or BMI of 27 kg per m2 or greater with associated complications (e.g., hypertension, diabetes mellitus, and hyperlipidemia).
I have already had requests in clinic for a prescription sent to compounding pharmacy. I am refusing to send prescriptions out of state or to compounding pharmacies, because of the FDA warning. Here: https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fdas-concerns-unapproved-glp-1-drugs-used-weight-loss. There are a bunch of issues: some compounding pharmacies are not using the FDA approved medicines, they are using something similar, but not the same. Also, the medicine does not come in the pen that injects a controlled amount. People have to draw the drug up and inject it. Some have injected ten times the amount that they should and have been hospitalized. It’s also worrisome that the compounding pharmacies, unlike state-licensed pharmacies, do not have to report complications.
A recent patient has deteriorating kidney function, with his creatinine jumping from 1.10 to 1.58. Creatinine is produced as a waste product by our cells and the kidneys need to clear it. His 1.10 was normal but the 1.58 is high, indicating the his kidneys aren’t clearing well, and that was only a six month interval. He is taking compounded semaglutide and compounded testosterone, with some online approval. That is, he did not get a prescription from our clinic. He started the semaglutide five months ago. The testosterone has been for years. “Stop the semaglutide and we will recheck your kidney function in a month.” His creatinine drops back to 1.10. Acute renal failure is listed as an uncommon side effect of the FDA approved semaglutide, but we don’t know if that is what he’s getting. I tell him the good news about his kidney function and say, “I think you should stay off the compounded drug.” I have not seen the same thing with the FDA approved semaglutide.
It’s complicated, isn’t it? We picked up the problem because he is on other medications and I do yearly labs on people who are on prescription medicines, to check whether their kidney or liver function is deteriorating. Almost all drugs, prescription or over the counter or supplements, are metabolized by either the liver or the kidneys. I only know of two that are not absorbed and not metabolized.
For the Ragtag Daily Prompt: pristine. I would like a pristine pill free body for as long as possible. Ok, I took one tylenol last week and I’d be dead three times over it wasn’t for penicillin.
No nightmares about clinic since the one I wrote about two days ago. I do feel like a bit of a dinosaur in clinic, though. Most of my older patients seem to really be fond of dinosaurs.
I’ve heard from other docs that they don’t have time to talk to each other in clinic either. Patient time but primary care we read all the notes from everyone: specialists, PT, OT, xrays, CT, MRI, ultrasound, lab, lab, lab, lab, prescription refills, phone calls. I read that people are trying to insert Artificial Intelligence into this. I am fine with a computer learning to read mammograms, but condensing information from notes? The AIs currently can “hallucinate”, and make things up. Is that worrisome or am I being silly? Notes are often wrong ANYHOW, way more than I would like. I saw a patient yesterday who has a neurological disorder. The hospital discharge note lists the wrong one! The patient caught the error, I didn’t. I am very glad he corrected me, but the hospital note is still sitting there wrong. Having been labeled with wrong diagnoses myself, I think it is a big deal. In order to fix it, he would have to fill out a form and the form would go to the physician, who is supposed to respond and add an addendum to the note. How often do you think THAT happens?
The discharging physician suggests he see a specialist for testing. I call that specialist and they agree with me: that testing is not indicated, it won’t make one bit of difference in his treatment. The discharging physician also suggests lung testing. I don’t think it works or is useful with a serious neurological disorder that affects muscles! Think, people.
My patient is grumpy and asks how we know the medicine is working. I reply, “You’re not dead.” Which is true. Undiplomatic, but he does not mind, because he is already saying, “What is the point of this?” To explain more about the medicine working, I ask, “Is your breathing better than when you went to the emergency room?”
“Yes,” he says.
“That is because the medicine is working.” I explain how it works and what happens if he stops it.
Sometimes it makes me feel heavy, heavy, like a dinosaur.
But I think I will try discussing my clinic day with my cat. I think she might enjoy it and I can clear the grumps out. And it’s not a hipaa violation! She doesn’t like other cats and won’t tell them anything.
I am waiting for approval or refusal from an official body regarding a job. The job was supposed to start on April 15, but the official body did not meet until April 17. (I am picturing a group of body parts getting together, arm, arm, leg, leg, head. Where is the pelvis? Probably out fooling around.) They initially said they would let me know by April 19 and then changed it to by May 1. So, any time between yesterday and May 1. This makes planning a bit difficult.
And weight. I drop ten pounds with pneumonia. I did not gain it back for a year. Then I went past my “normal”, about ten pounds. Now I have come down six pounds. I am not taking one of the weight loss drugs. I am just reducing sweets and also letting my self be just a little hungry and walking. I am not losing weight fast. My goal is about 2 pounds per month.
The last three days my appetite has dropped, which is a stress sign for me. I am taking my friend to get radiation and it took four hours on Thursday and three yesterday. I have to back off if my appetite goes. The combination of waiting and taking care of her is a bit too much. Partly because there are multiple snafus, in both arenas. (Now I am picturing the body parts gathering in a football arena. Wordplay.)
Today I do not have things on the schedule. I may just putter and write and think, feed the cats, do laundry. Nothing much.
How about some music? The first one is a psychedelic band album: new to me. The second is a song sung by Rotarians in the 1960s. Maybe now too, though not by our club.
Sometimes water looks light and flighty in photographs, but here is Crocker Lake, with the water looking thick and deep. A mirror, inviolate. A surface that we can almost believe we can step on. Water IS heavy.
_________________________
The weight of water
You don’t realize the weight of water
I say I am a sea, deep, the emotions on the surface only you dismiss me, female, lesser, emotional, unimportant except for your uses. I should be receptive, listen, not speak. You have no interest in my life, except when you want my services.
You don’t believe me until the day you look down and fall. The waters close over your head. The weights you’ve tied around your ankles carry you down down. Welcome to the depths.
Sorrow weights my chest like lead: breathing is hard. Today I can cry for a minute or so and then that is over. Sorrow teething tearing at me from inside like a crow’s beak sharp pointed poking grabbing tearing winter break approaching everyone goes insane buying drinking drugging bearing the cost into the New Year deepening woes I miss the dead: father sister mother Read my mother’s journals when I am ten She writes about art and us and other friends dead. Her voice clear again. My mother is my age when she dies. Her younger voice: memory smiles and cries.
I am a rural Family Medicine doctor, board certified and board eligible. I have used the Telemedicine groups in the nearest big University Hospital since 2010.
Initially I started with the Addiction Telemedicine. I accidentally became the only physician in my county prescribing buprenorphine for opioid overuse in 2010. I panicked when I started getting calls. Dr. Merrill from UW had taught the course and gave me his pager number. I acquired 30 patients in three weeks, because the only other provider was suddenly unavailable. Dr. Merrill talked me through that 21 day trial by fire.
I think that I presented at least 20 patients to telemedicine the first year. The telemedicine took an hour and a half. First was a continuing medical education talk on some aspect of “overuse”, aka addiction, and then different doctors would present cases. We had to fill out a form and send it in. It had the gender and year of birth, but was not otherwise supposed to identify the person. TeleAddiction had a panel, consisting of Dr. Merrill (addiction), a psychiatrist, the moderator/pain doctor, and a physiatrist. Physiatrists are the doctor version of a physical therapist. They are the experts in trying to get people the best equipment and function after being blown up in the military or after a terrible car wreck or with multiple sclerosis. There would usually be a fifth guest specialist, often the presenter.
After a while, TeleAddiction got rolled into Telepain and changed days. They added other groups: one for psychiatry, one for HIV and one for hepatitis C. These can all overlap. I mostly attend TelePain and TelePsychiatry.
After a while, I pretty much know what the Telepain specialists are going to advise. So why would I present a patient at that point? Ah, good question. I use Telepain for the weight of authority. I would present a patient when the patient was refusing to follow my recommendations. I would present to Telepain, usually with a very good idea of what the recommendations would be. The team would each speak and fax me a hard copy. I would present this to the patient. Not one physician, and a rural primary care doctor, but five: I was backed up by four specialists. My patients still have a choice. They can negotiate and they always have the right to switch to another doctor. Some do, some don’t.
I am a specialist too. Family Practice is a specialty requiring a three year residency. The general practitioners used to go into practice after one year of internship. My residency was at OHSU in Portland, with rotations through multiple other specialties. We rotated through the high risk obstetrics group, alternating call with the obstetrics residents, which gave me excellent training for doing rural obstetrics and knowing when to call the high risk perinatologist. In my first job I was four hours by fixed wing from the nearest more comprehensive obstetrics, so we really had to think ahead. No helicopter, the distance was too far and over a 9000 foot pass, in all four directions. That was rather exciting as well.
Discover and re-discover Mexico’s cuisine, culture and history through the recipes, backyard stories and other interesting findings of an expatriate in Canada
Engaging in some lyrical athletics whilst painting pictures with words and pounding the pavement. I run; blog; write poetry; chase after my kids & drink coffee.
Refugees welcome - Flüchtlinge willkommen I am teaching German to refugees. Ich unterrichte geflüchtete Menschen in der deutschen Sprache. I am writing this blog in English and German because my friends speak English and German. Ich schreibe auf Deutsch und Englisch, weil meine Freunde Deutsch und Englisch sprechen.
KO Rural Mad As Hell Blog 