Meditation Pearls

I'm taking a class called Mindfulness Based Stress Reduction. Based on the work of Jon Kabat-Zinn at the University of Massachusetts, it is basically a meditation class. This is the beginning of the 5th week out of 8 weeks. Over the course of the course, as it were, the teacher has offered up some good one-liners to help us. Here they are, so far.

• The mind can only be in one place at a time.
  
• You can only change in the present.
  
• Every thought is accompanied by a physiological response.
• Consciousness is contagious.
• Bring it back, baby! (the mind to the breath)

Meditation is simple and difficult. If you've ever tried it you know. Bringing my attention back to the feeling of my breath, over and over and over and over again. And again. Each time my focus comes back to the breath, thoughts roll off like water off a duck's back. For a fleeting moment I am in the present moment. Right here, right now. Then before you know it I'm off on a trail of thought again and I don't even notice it until I'm halfway to tomorrow. Oops, there I go again! Bring it back, baby!

Do that about a thousand times in ten minutes, and that's a medication practice.

H1N1 is here

It’s true. Swine flu is here. It is all over New Mexico including here at UNM. Have you had it yet? How about your friends and classmates? How many are out today with flu? I’ll bet there are at least a few, and there will likely be more next week.

We have seen lots of H1H1 influenza or “Swine Flu” at Student Health and Counseling. Since September 1st we have had over 100 cases of “influenza-like illness.” Most of these were H1N1. All have recovered. And those are just the ones who have come to the clinic. There have been many more cases where people just stay home and take care of themselves.

The virus continues to spread. It is very contagious and likes young people. Chances are good that you’ll get it, and chances are excellent that you’ll survive. Here are some tips to help you manage before, during and after you get H1N1.

Before you get sick: Get the regular seasonal flu shot. Make sure you have basic medications at home for fever, cough and congestion. Buy a thermometer, and maybe some soups and juices. Once you have flu you won’t feel like going out to the store for this stuff, and they won’t want you there spreading germs. So stock up. Try to avoid getting the flu by staying away from sick people, keeping your hands away from your face, and washing your hands often. Get plenty of sleep and eat well so your body is strong for the fight against germs.

Once you are sick: Flu symptoms are fever over 100.5, cough, body aches, sore throat, headache, chills, fatigue, and sometimes diarrhea and vomiting. If you have some or all of these you might have flu. Take to your bed! Drink lots of liquids and treat your symptoms. Expect to be out of commission for five to seven days. Please do NOT go to work or school or out to eat at a restaurant! I know students who have done all of these things. If you go out in public you are putting others at risk. Be considerate and stay away. Contact your professors by email or phone to let them know you are sick.

Should you get medical care? If you are a basically healthy person who gets the flu, you probably don’t need to see a doctor. Self treatment at home is usually adequate. If, however, you are pregnant, have asthma or other lung problems, are under 2 years old or over 65, or have any chronic medical condition, you should seek care. There is a medication called oseltamivir (Tamiflu) that is recommended for people in these high risk groups, to decrease the risk of flu complications like pneumonia.

If you are not in these risk groups, there is a small chance that you could still get seriously ill from flu. We have all heard the stories of people who died from H1N1 who had no underlying medical problem. Those stories are scary to be sure, but thankfully also very rare. It is unlikely to be you. That said, if you do get any of the following symptoms, regardless of who you are, please hustle in to the nearest emergency room:

Severe difficulty breathing, severe pain in the chest or belly, sudden dizziness or confusion, severe or persistent vomiting.

After you recover. First of all, this takes a while. As I said before, expect to be out of commission for five to seven days. That means at home resting. Even after the worst of the symptoms have passed, you’ll be weak and easily tired for several days. Take it easy. Don’t return to sports until you feel really good.

Once you are well, step outside and take a deep breath of our crisp Fall air. Stretch your strong body, look up at our New Mexico Blue sky and give yourself the gift of gratitude for your life and good health.

Doctor's Notes for School and Work

What is it with teachers and employers requiring doctor's notes? It is a silly requirement that wastes a lot of everyone's time. This has become one of my pet peeves.

I work at a university. The students are paying to come here and get an education. They are responsible for their own learning. This includes, in my mind, deciding whether and when they'll go to class. If they decide that they'll get more out of reading the book than attending the lecture, that's their choice. I had a classmate in medical school that showed up only for exams (no classes) the first two years. He is now a successful physician. If students get sick and decide they need to stay home and rest, more power to them. That's probably where they belong. Home resting, letting their body heal.

When a teacher requires attendance, she is deciding for the students that the class is worth their time, every time. When she requires a doctor's excuse for absences due to illness, she is making a decision for this adult as to when they need to go see a doctor. Sometimes all a person needs is a few days in bed. Not a visit to the clinic, not a doctor to confirm that yes, in fact, they have a cold, or a stomach virus. Many of our patients know this. They get sick, they go to bed. But then, because their teacher requires a note, they come in to the clinic, wait with all the sick people (possibly catching a new germ in the process), then waste their time and ours telling us they were sick and stayed home and asking for a note. The next time they get a cold, they'll come right in, knowing they'll need a note. It sets up a pattern of unnecessary office visits and contributes to the culture of dependent patients who think they need a doctor for every little sniffle.

It's ludicrous. In my humble opinion.

H1N1 - article in last week's Daily Lobo

In polite company we call it Novel H1N1. It’s the Influenza Formerly Known as Swine Flu. Originally thought to come from pigs, this flu virus is actually a mix of pig, bird and human. Believe it: only a virus could pull off that combination.

This rascal made a big splash last Spring, as you no doubt remember. After making its debut in the southern hemisphere it worked its way north, and by late summer there were so many cases the CDC stopped counting.

The media hype is hopping about this new germ, and lots of people are afraid. Since it is a new germ, and we haven’t been through a winter with it yet, there is a fair amount we don’t know. But what we do know is reassuring. Most of this comes from statistics but some comes from experience: we have already seen several cases here at Student Health and Counseling.

So far it looks like H1N1 is going to be gentler than the regular flu. Most cases of H1N1 are mild, and over with in a few days. Yes, there have been deaths around the country, but mostly in people who had serious medical problems. If you are otherwise healthy when you get the flu, you can put money on your survival.

Still, any flu can be miserable, so I suggest you don’t catch it. How to avoid it? Keep your hands off your face! That’s the best thing you can do. The flu enters your body through your respiratory system. That means through your mouth or your nose. How often do you pick your nose or your teeth? Don’t answer that. Just know that if the virus is on your hands when you touch your face, you’re toast.

Before I go further, I need to teach you a new word. Fomite, pronounced with a long O and a long I, accent on the Fo. Fomite is a medical term that means any object that can carry germs and pass them along. Fomites are things like towels, drinking glasses, pens, money. Here’s why this word matters.

The H1N1 flu is passed in large droplets. That means if a flu patient coughs, the virus flies out of their mouth in droplets. The droplets then fall onto the nearest surface. H1N1 doesn’t hang around in the air for long, unlike some other viruses that are passed in smaller, lighter droplets. How do you catch the flu then? Either you were unlucky enough to be in the line of fire when that person coughed, or – and here’s where that new word comes in – you touched a germy fomite and then touched your own face.

Think about it. Our hands are everywhere. We use them for everything. Opening doors, using a phone, handling money. As soon as you touch a fomite, your hands are host to whatever little nasties got on there from the other people who touched it. Then you wipe your nose or rub your eyes and wham. Germ transfer.

Yes, it is important to wash your hands, especially before you eat or otherwise touch your face, but washing your hands isn’t enough. The germs don’t soak in through your hands to make you sick, after all. So wash and sanitize, by all means, but mostly keep your hands off your face. If you have to touch your face, like to eat or put on makeup, wash your hands thoroughly first.

Besides washing your hands and keeping them off your face, take good care of your body in the usual ways so that your immune system is on max alert at all times. Sleep enough. Eat well. Exercise regularly. You know the drill.

If you’re already sick, please be responsible and protect others. Keep away from people! If you get symptoms of the flu, stay home! Symptoms are primarily fever, cough, and body aches. You might also have a sore throat, stuffiness or stomach upset. H1N1 typically comes on over a short period of time. Like a Ferrari that goes from zero to 60 in a matter of seconds, H1N1 will rocket you from well to miserable in a matter of hours.

If you are sick, cover your cough. Not with your hands! The latest official advice is to bend your arm at the elbow and cough or sneeze into your elbow, or the fabric of your sleeve above the elbow. If you choose to spray your germs into a tissue, fine, but then please discard the tissue and wash your hands.

The best treatment for H1N1 is rest. Your body is a pretty efficient virus-killing machine, but it needs your support. Stay in bed, drink plenty of fluids, and take medicines for your symptoms. Acetaminophen or ibuprofen for fever and body aches, dextromethorphan for cough, phenylephrine for congestion, or pick your own personal favorite.

If you decide to go to the clinic for H1N1, you’ll probably leave with nothing more than good advice. There are some anti-viral medications on the market, but so far they’re only being used for flu victims that are so sick they need to be in the hospital. Those are the folks with chronic medical problems like asthma, emphysema, diabetes and others. If you have a chronic medical problem and you get sick with flu, you should definitely seek medical care, and you might get treated with antiviral medication. But if you are the typical UNM student, young and healthy, it’s better for you and the rest of the community if you stay home.

UNM is doing its part. We’re expecting an H1N1 vaccine, probably in October, and we’re planning for campus-wide vaccinations. In the next few weeks, watch for announcements about the regular seasonal flu shots, which will be free of charge this year. Meanwhile, you’ll see hand sanitizers around campus, along with signs reminding you to wash your hands. SHAC has provided flu kits to the dorms, with thermometers, surgical masks, hand sanitizer and Tylenol. If you get the flu and you live in the dorms, LaPo will bring you "flu meals." Professors have even agreed to lighten up on asking for doctor’s notes if you have the flu.

For more information, visit our website.

Women Veterans in NM - some numbers

Yesterday I spent the day at a conference for women veterans, designed to provide information and resources for everyone from WWII WACs (and there were two of them there) to Viet Nam Vets to active duty OIF/OEF (Iraq/Afghanistan) personnel, and everyone in between. Not a veteran myself, but with a blossoming interest in a second career in veteran health, I went to learn. Here are some numbers I learned.

New Mexico has 200,000 veterans. Of these 16,000 are women. That's about 8%. Of all the veterans in NM, only about 40,000 have even applied for veterans services and benefits from the state. That means three out of five vets could be getting benefits they aren't getting. At the state level, these range from a free fishing license to scholarships and property tax breaks.

More women are currently in service. Of all American active duty, 15% are now women. The women vets I met and heard yesterday were all very proud of their service and deeply loyal to their country.

The presence of women in the military has brought to light a phenomenon termed MST, or Military Sexual Trauma. This is any kind of sexual harassment or assault experienced while in the military. The Veterans Administration now has a MST coordinator at every facility in the country. Every vet, male and female, who applies for services now gets asked if they experienced MST. They can answer "Yes," "No," or "I don't want to answer." In 2007, 25% of American women vets screened answered Yes.

Of course there was discussion of PTSD, and one speaker reviewed some of the alternate terms being considered for this. There's a move to get rid of the part that says "disorder" so as to reduce any perceived stigma. "Trauma Stress Injury" was my favorite of those mentioned.

There were more numbers, like Chapter 33, which is a GI bill specially for those who serve after 9/10/2001 in OIF/OEF. And 20%, which is how disabled you have to be to receive vocational rehab on the VA's penny. And 22, which is the number of days Shoshana Nyree, the first female American POW of the Iraq war, and our guest of honor, was held before the marines rescued her. (She has a book coming out soon titled Still Standing)

Numbers can be impressive. I know I was impressed with the number of services and benefits available to veterans. I believe they have earned it, and I hope it all helps. And I know that behind the numbers and the statistics are real live women and men, some damaged so badly that no matter what number of services they get they will never heal.

ROTC Physicals

I did three ROTC physicals today. ROTC stands for Reserve Officers' Training Corps. In return for financial assistance for their college expenses, students complete training sessions while in school, and fulfill a military commitment once they're out. They graduate as officers, bypassing the unlisted ranks.

My job was to make sure they didn't have any glaring physical problems or contagious diseases that would prevent them from doing the rigorous PT (Physical Training) program.

All three of these young people were vigorous, healthy and intelligent. Each had an upbeat attitude about their education and their future. They were polite and correct, answering my questions with "Yes Ma'am" and putting their best foot forward.

As I handed the finished paperwork to the last patient, he thanked me with a breezy smile. I looked at this young man, healthy and whole, and marveled that he and the others would voluntarily take this step. The first step on a path that could lead to unknown lands, to injuries of body and soul, even to death.

"Thank YOU for your future service," I responded. His face softened and this time his smile reached his eyes .

Forgiveness

Forgiveness is good for your health. Really. They've done studies on it. People who are 'forgivers' have lower blood pressure and pulse, fewer physiologic stress responses, and more positive emotions. They also sleep better, are more energetic, have fewer physical symptoms and use fewer medications.

Sounds like a no brainer. Let's all be forgivers. Too bad it isn't as easy as it sounds, eh?

What is forgiveness anyway? What does it mean to forgive someone? Say somebody hurts you in some way. They say, "I'm sorry." You say, "That's okay." Have you forgiven them? What if it really isn't "okay?" What if it will never be "okay" what they did? What are you going to do?

"I forgive you" sounds like it's more about what I do to you than what is going on in my own mind. It even has a slightly haughty, patronizing tone to it, as if I'm anointing you or something. But forgiveness isn't something you do TO someone. In reality, forgiveness has little to do with the other person.

If you forgive someone, that doesn't mean you condone what they did. It doesn't mean you excuse it, or even that you think it was "okay." It doesn't mean you will forget what happened, or even necessarily that you reconcile with them. Forgiveness happens in your own mind, and is a process of letting go of the anger and resentment you have. How do you do that? You make a decision that you will not allow those thoughts to dominate your well being or mess with your peace of mind. We control our own thoughts, after all. You can decide what you will or won't think about or dwell on. Our thoughts create our experience to a huge degree.

Thoughts can open the back door for unwelcome feelings to come in. If you hurt me, I can decide to stew about it. "How dare she? I can't believe what she did! That really hurt me. Ow! She's such a *&^%!" etc etc. If I start thinking like that, anger and resentment will soon be invading and before I know it I'm hogtied in my own kitchen. Who wants that? Not I.

You cannot count on someone who hurt you to apologize, to try to make amends, or even to recognize that they hurt you. If you hold your breath for any of that, well, you'll suffocate, that's what.

Let it go.

Trisomy 18

(I'm bringing this old post back up top because it is one that keeps getting comments as people who struggle with Trisomy 18 search for answers and community)
Warning: In spite of the scientific title, there won't be much science here. However, this is a sad story with gross details, so don't read it if you're squeamish.

Tarik and Caroline were having their second child. Their first was a healthy toddling boy, a lovely combination of their two cultures. Tarik and Caroline were both young, both healthy, responsible professionals on their way up. Naturally, therefore, they got in to the clinic early in the pregnancy. I was the lucky Family Practice resident that "picked them up". I'd get to see Caroline for her prenatal visits, checking her blood pressure, urine, weight and measurements to make sure all was progressing normally. I'd be the one to find the first heartbeat for her, to feel the baby's growth at each visit, to marvel with her as baby rolled and kicked inside her, to advise her about diet and exercise. Routine stuff. We'd meet every month at first, then with increasing frequency near the end. At her 36th week (out of 40 full term pregnancy weeks) I'd turn my pager on 24/7 for her, so that I'd be able to deliver the baby whenever she went into labor.

I loved OB. The miracle of a human baby growing inside another human never failed to fill me with awe. We think we're such hot stuff, such modern, technological super-beings. Our lives are filled with devices, with increasing automation and mechanical sophistication. But when it comes to bearing children, we're animals all the way. What is more bestial, more natural, than growing your young inside you, pushing them out with blood and tears, and nursing them at your teat? We in medicine do our best to technologize this experience with beeping gadgets, powerful medicines and invasive procedures. But at the core, nature is in control, a fact that charges the labor and delivery wards with excitement and fear. Birth can be a miraculous, happy event, and usually is. But it can also be a terrible tragedy, anticipation turning to anguish at the last minute.

Round about Caroline's 15th week, her uterus began to measure bigger than it should. We weren't alarmed at first. Could be mis-measurement. Could be a big kid. Could be twins...twins? There were twins in the family background. Hmmm. Since the large size persisted, we decided to get an ultrasound. Nowadays just about every pregnant woman gets an ultrasound routinely, but back then (a long 17 years ago) we had to have a reason.

By the time she got the scan, she was at 17 weeks. By then, the embryo has become an infant, fully formed but small, with weeks of differentiation behind it and weeks of growth ahead. The scans are highly sensitive, able to discern organs clearly.

There was something wrong with Caroline's infant. The heart didn't look right. There weren't four distinct, regular chambers. Further testing was advised. I met with Caroline and Tarik, gave them what scanty information I had, tried to reassure them or at least postpone panic, and suggested an amniocentesis. We didn't know what the problem was, exactly, or how bad it was. Some congenital heart defects are fixable by the surgeons. Some are not. Some are associated with chromosomal abnormalities, which is why the amnio was recommended. More frightened about the infant's condition than about having an 8" needle stuck in her belly, Caroline agreed.

If you watch crime shows on TV, you probably think that DNA results are available just as soon as the patient gets up off the table. Not so. Caroline and Tarik had to wait two agonizing weeks to discover what they were dreading to know.

The baby had Trisomy 18. An extra chromosome. Three of the #18 chromosome instead of two. Well, so what? Sounds pretty benign. After all, we have what, 46 all together? What's one extra chromosome among friends? Well, it turns out that one little #18 chromosome has more power than all the others put together. It is a tiny tornado, packing a destructive force stronger than life itself.

Half of all babies born with this condition die in the first week of life. 90% of them have heart defects. Most of them have other defects as well, including spina bifida, cleft palate, deafness, joint contractures, and mental retardation. Only an unlucky few survive beyond a matter of weeks, and those don't last much longer. The term that is branded in my brain from our meeting with the genetic counselors is "incompatible with life". Caroline was carrying a child that was incompatible with life. As soon as it hit the outside air, it would begin to die. She. "It" was a she. They could tell that from the genetic analysis too, of course. She was doomed.

After listening, reading, thinking, talking and crying together, Caroline and Tarik told me they decided to terminate the pregnancy. They couldn't face the thought of birthing a baby girl only to watch her die in agony. This was the right decision. I had no doubt, and nor did they. I offered to accompany them to the procedure, and they gratefully accepted.

They went to one of the local abortion clinics for this procedure. The doc there was very experienced in terminations at all stages of pregnancy, though of course most were done much earlier. By chance and good luck, there were no protesters outside the clinic that day. I was prepared to give them a piece of my mind if there were any. Caroline was not the typical abortion patient, and did not deserve to be hassled.

Without much delay, we were shown into the procedure room. Tarik was told to wait in the waiting room, per clinic protocol, making us all glad I had come along. The staff was kind and efficient, helping Caroline gently onto the table, talking in soft voices, explaining and reassuring. Caroline tolerated the procedure very well, holding my hand tightly and breathing deeply as the obstetrician dilated her cervix and removed the infant. Caroline didn't cry, not then.

A termination at 21 weeks is very different from one at 7 or 8 weeks, the usual time an "elective abortion" is done. The early abortions are done with suction, and the "products" just look like so much bloody mush. At 21 weeks, there are organs. There are limbs. There are bones. And the procedure is done not by suction, but by "extraction." Fortunately, Caroline and Tarik were forbidden to look at what was left of their defective baby girl. But I, as a medical provider, was invited into the side room to further my medical education. I had to steel myself, calm my heart, open my scientist mind.

Her little blue hand, curled and lifeless on the surgical towel, is forever wrapped around a tender neuron in my brain. As I looked at the pieces of this ruined life, what I felt was not revulsion or nausea, but a deep sorrow. I knew this was the right choice, the right decision for these parents and for the mutant child, for that's what she was. It was the humane, loving choice for all involved. But that didn't make it easy.

Aching in the depths of my heart, I returned to Caroline. She was resting in recovery now, out of the stirrups, and Tarik was with her. I tried my best to push my own feelings down deep, to put on my doctor face and stay calm. But when Caroline opened her arms for a hug, my humanity came crashing in, and my tears fell with hers.

Narcotic Narcissism

What was I just saying about lessons you have to learn over and over?

I'm smacking my head - but gently - this week as I relearn the narcotic lesson. Patients addicted to narcotics will do just about anything to get their drug. It is a powerful poison. Normally nice people will get nasty. Shy people will haul out their inner drama queen and wax poetic. Scrupulous people will lie, cheat and steal. They don't mean any harm by it, honest they don't. They're just trying to get their needs met. And once they get their drugs, they're the picture of contrition.

If it sounds like I'm painting a large group of people with one wide brush stroke, well, I guess it's because I am, in a way. I'd be the first to declare that each of us is an individual, but, that said, I have to assert that narcotic addicts have a lot in common with each other.

Is someone who uses narcotics for legitimate pain an addict? Of course they are. Anyone who takes a narcotic in high enough doses for a long enough time becomes addicted. Physically dependent. Their body needs the drug in order to feel good, and if they don't get it, withdrawal is extremely uncomfortable. Miserable, to the point that they'll do all those things I mentioned above. They'll make raving lunatics or groveling fools out of themselves rather than go without.

As a physician, I struggle with the dueling forces inherent in taking care of a narcotic addict. I don't want anyone to have unnecessary pain. I also don't want to be manipulated. I truly believe the addict has no ill intention toward me when he/she lies or cheats to get drugs that are needed to treat the pain. At the same time, I can't help but feel angry, at the addict for deceiving me, and at myself, for being too gullible, for believing the tales and the tears once again. I also feel an irrational anger at the medical system, at the pharmaceutical companies, at the chemists who don't develop alternative medicines that are as effective and yet less harmful.

My experience with pain patients tells me that not all of us are born addicts. However, some of us are. There's a definite difference in brain chemistry between people that makes some of us far more likely to end up addicted than others. Some of my patients with acute pain, like that from a broken bone, will only take a couple narcotic pills and flush the rest. Others will still be trying for refills long after the bone is healed.

It doesn't seem fair. My lesson patient this week was injured in service to his country. His wounds are as real as his pain, and both are with him for life. Narcotics are the only meds that help. But because we have so few alternatives, he'll be a slave to their destructive seduction the rest of his days.

Lessons from Fence Wrecking

This past week I've been spending some time wrecking fences up here at RMBL. The old fences, while picturesque in places, are thoroughly falling down in others. Nowhere do they do much any more to keep the cows, expected in July, out of the townsite. So down they must come. It is highly satisfying work. Not only did I get to take any aggression I had out on rotton logs, but, even more important since I can't seem to drum up much aggression up here, I got to see progress, and an end point.


As I worked today, I thought of some of the life lessons that can be learned and relearned when one is doing something like fence wrecking:

1. If you focus on one pole at a time, before you know it you've done a whole section.
2. Work with the forces of nature when possible. Gravity is your friend.
3. The right tool can make a big difference.
   
4. Watch the experts. They know what they're doing.
5. Sometimes getting the right angle works better than force.
   
6. If someone offers to help, say yes!
7. A little bit of rest goes a long way.
8. Plan ahead or you might have to move the whole pile.
9. You'd be surprised at the load you can carry if you have your balance right.
10. Share your snack!