Monday, December 21, 2009
The Facebook page title is the same as the book title.
Sunday, November 29, 2009
Why? Why bother? What is the point?
As a beginning meditator I'll offer my thoughts. The main reason to carry the present-moment awareness skill into daily life is so that you can live this life -- as it happens -- to the max. If you are really right here, right now ALL the time (good luck with that, but it's worth trying) then you will have the full, real experience of your life. You won't be distracted from whatever is going on by ruminating over the past or worrying about the future. You'll HAVE this moment in all its glory. Or sorrow, pain, joy, whatever it is. You'll be right there, rather than some-where else or some-when else, like most of us usually are.
Another reason I have found for meditating is that the skill of bringing my mind back to the present serves me in relationships. During an interchange, if I am able to hear the other person, to see them as they are right here, right now, without past baggage or future fear getting in the way, things between us go much better. Talk about challenges! But on the rare occasion when I get a glimpse of this, I see the value.
Beyond these, there are the health benefits of meditation, which are becoming more documented with each passing day.
I'm sure I'll find more of my own personal reasons to continue meditating as time goes on. For now, this is enough to get me onto the cushion for 20 minutes each morning.
Friday, November 13, 2009
In medicine, there is no big event for which we're preparing. We just practice every day. There are the usual jokes, like "someday maybe I'll get it right" and so forth. But for the most part, "I practice medicine" is just another way of saying "I'm a doctor." I don't know any other profession that uses that term. Do you? A mechanic doesn't say, "I'm practicing auto mechanics." Imagine your chagrin if he did! A teacher doesn't say, "I practice education." He better not; not with my kid in his class! But nobody seems to mind that their doctors are practicing.
About a month ago I began another kind of practice: meditation. Here again is an activity for which the practice is the activity, is the point. Sure, some people say or think, "I'm meditating now" but I think most or many experienced meditators refer to it as "practicing meditation." I really like that. If I thought I were practicing for some big meditation performance, which I had to pull off without a false note, I'd have given up after the first five minutes!
Meditation is practicing. Every time I bring my attention back to my breath it is like playing a note in tune just for a moment, before my unruly mind goes stumbling all over the neck of the cello again.
Thursday, November 05, 2009
- 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)
Do that about a thousand times in ten minutes, and that's a meditation practice.
Sunday, November 01, 2009
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.
Wednesday, October 07, 2009
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.
Wednesday, September 16, 2009
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.
Sunday, September 13, 2009
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.
Monday, August 17, 2009
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 .
Friday, July 10, 2009
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.
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.
Friday, July 03, 2009
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.
Friday, June 19, 2009
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:
- If you focus on one pole at a time, before you know it you've done a whole section.
- Work with the forces of nature when possible. Gravity is your friend.
- The right tool can make a big difference.
- Watch the experts. They know what they're doing.
- Sometimes getting the right angle works better than force.
- If someone offers to help, say yes!
- A little bit of rest goes a long way.
- Plan ahead or you might have to move the whole pile.
- You'd be surprised at the load you can carry if you have your balance right.
- Share your snack!
Wednesday, June 17, 2009
Gothic Mountain through aspens up Copper Creek trail.
This guy was right by the road.
Sneak preview of the Maroon Bells wilderness, from Copper Lake trail.
Avalanche damage up valley from Gothic.
Monday, June 15, 2009
Just outside the dining hall I was graced with a view of this red-headed woodpecker.
This is the road just below the cabin, after a rain. Can you make out tracks for human, deer, mountain bike and car? If not, sorry for the lousy pic!
Sunday, June 14, 2009
Here I am in the picturesque Rocky Mtns of Colorado. When friends heard I was coming here, they said, “Oh, what a great place to write!” A quiet cabin, a rushing river, alpine beauty, no phone or family to distract me. Nine thousand feet, up where the air is clear. Sounds idyllic, doesn’t it? And yet the words don’t just flow out of me after all. No effortless inspiration blowing in with the mountain breeze. It got me thinking.
What makes a great place to write? Yesterday while I was wrecking fences I realized two things. One, wrecking fences is a great activity to do when you need to think. You know how some people say their best ideas come to them in the shower? I believe it’s the same phenomenon. Wrecking fences, like washing your bod, is an activity that takes a fair amount of immediate concentration. Much of my brain was occupied with crowbar angles, logs, piles, lifting, hauling etc. I had to be aware of what I was doing right then and there, or I could get hurt. This doesn’t leave much brain for anything else, but it does leave some, and I think that’s when and why creative breakthroughs can happen. Your mind is so focused on one activity that the usual chatter is suppressed, diminished. What’s left over is a clear channel through which insights may pass.
The insight that passed through the brain channel that fence wrecking opened was that internal environment is much more important than external environment. Some people have their writing spot, specially set up just the way they like it, and that’s where they write. Others write on napkins, at the soccer field, in their semi truck after a day of driving. I think the one thing successful writers have in common is that, regardless of their physical setup, their internal environment is focused, calm, and alert. How you arrange that internal environment is the key to your success. Myself, I find that doing something physical first (like my current favorite, fence wrecking) seems to knock the kinks out, blow the dust off, clear my mind.
The third realization, which came to me later, for the zillionth time, is that I learn the same lessons over and over. Knowledge comes in layers, and the deeper layers carry echoes of those above them. I have had both of the above thoughts before, in different renditions. They still felt like realizations this time around. I laugh as I peel this layer, recognizing it again, wondering if I’ll ever really fully understand anything.
Thursday, June 11, 2009
Work Day at RMBL. It rained and snowed all day, but the intrepid fence-wreckers were not fazed! Here I am with crowbar in hand, happily demolishing the old buck and rail fence to make room for a new one.
These two greeted me outside my cabin in the early morning. Mama and yearling.
Fog on Gothic Mtn.
I never tire of this view of Avery Peak from my front porch.
Friday, June 05, 2009
I'm so pleased to be back in Gothic, Colorado, at 9,500 ft elevation. Spring has barely begun here, as you can see. Lots of snow still on the mountains, and water pouring off all over the place. What a difference from the 90 degree high desert I left in Albuquerque!
My official role here this year is minimal as far as doctoring goes, so I'm excited to get a lot of writing work done. More pics coming, as soon as I get new batteries to replace the ones that froze last night (along with the milk in the fridge and my toes in my sleeping bag!) Fortunately, the groundsperson Robyn connected my gas tank today and there's a wall heater, so hopefully I'll be cozy tonight. If the heater doesn't work, I'll sleep with my camera to preserve the batteries!
Wednesday, June 03, 2009
Tuesday, June 02, 2009
Patient #1. Woman in her 30's who drank so much alcohol in one sitting that it messed up her blood electrolytes which messed up her heart rhythm and she had a cardiac arrest. She was resuscitated but meanwhile lost blood to her brain resulting in brain damage. She now has virtually no short-term memory, can't be left alone or she'll get lost or burn down the house, can't work. Cheerful and half here, she is a victim of her own poor choices.
Patient #2. Man in his 50's who has done heavy work all his life, resulting in accumulated wear and tear to the point where he can't move without pain in his back, hands, knees. Deeply wishes he could still work, and cries throughout the exam, not from pain but from the frustration of not being able to work. This one hits me hard.
Patient #3. Five year old boy with muscular dystrophy. Mentally sharp as a tack, physically weak in the large muscles. When asked if he can walk, hops down from his wheelchair and careens across the room in a clumsy, enthusiastic waddle. "Sure!" he exclaims. I fall in love.
Patient #4. Young woman who was a passenger in a car going 75 on cruise control on the freeway. Over a rise and out of sight, an old truck full of rocks stalled in the middle of the road. The car slammed into the old truck, causing a rock fall in addition to a 75 mph dead stop. Thankfully, she and her 6 month old in utero child survived, although her face and jaw will never look the same. Life can change in a split second.
Saturday, May 09, 2009
Thankfully, the final decision is not mine. It's hard enough making some kind of statement about how each "allegation" (the official term for the medical condition that is affecting the client or claimant) impacts the health and functionality of the client. Many cases involve pain, which is very hard to objectively document.
Naturally, I can't mention specific cases here, at least not in enough detail to be able to identify anyone. I have already seen a huge variety of medical problems, from amputations to aneurysms, back pain (lots of that) to bipolar disorder. Plenty of suffering. Everyone suffers. But are they suffering enough? Enough to get a government handout? If a man has been a plumber all his life, and can no longer crawl and kneel, what should he do? Should he be required to learn a new skill after all these years? Should he kick back and live on disability payments? What about the young person who has years of productive life ahead of them? Should a car crash that leaves them with occasional or even frequent back pain ground them for life?
I don't know the answers. I do know that some of the people I examine seem very disabled, and some don't. Are there scammers in the lot? Probably. There are also frustrated hardworking people, embarrassed at their unintended impotence and wishing they were back on the job this minute. There are also bewildered disenfranchised folks without health insurance who are hoping to access health care through this particular back door into the system.
No doubt I'll have more to say on the subject with time. I'm learning a ton.
Thursday, May 07, 2009
My process has evolved over the years. I never planned ahead what my process would be, but it has come to a pattern that looks something like this.
- Pick a topic. Either choose from a question sent by a reader or, if none have come in, pick something timely. Example: health during finals week (last week's topic, published yesterday)
- Research a bunch online, using both medical and lay sites. Some of my favorites are NIH and CDC. Copy and print key stuff, or copy and paste into a research doc.
- Write a terrible, rambling, ungrammatical verbal vomitage, full of sentence fragments, runons, slang, random unrelated thoughts, anything that comes to mind.
- Go away.
- Come back to it and look at it. Lo and behold, a flower or two arises from the garbage. Dig out the flowers and transplant them into a new document.
- More verbal vomit of ideas I've digested since the last purge.
- More garbage gardening.
- Leave the stinking pile and move full time to the new document, pruning, filling in, spiffing up.
- Go away again, preferably overnight.
- Come back, tweak and polish. Done!
Saturday, May 02, 2009
Meanwhile, there's a second pandemic, a worldwide infection of that most resistant of viruses, fear.
"How scared should I be?" people ask me. Interesting question. Fear, although occasionally useful for motivating us to do something important, like get out of the way of a speeding truck, usually does more harm than good. Fear causes you to lose sleep, to get bellyaches and headaches, to get distracted from your responsibilities and your happiness. Fear is living in the future, and who knows if that future will ever materialize the way your fantasy has painted it?
I don't recommend stirring up fear, in yourself or anyone else. How scared should you be? Not scared. Responsibly behaving so as to avoid catching the swine flu, sure. Staying informed about the disease and the latest recommendations, absolutely. But there's no point in worrying about a potential future catastrophe. You're more likely to get killed in a car wreck than die of swine flu. So pay attention when you cross the road. Pay attention to your life, right now, in this moment. As one of my favorite authors says, we only have moments to live! One at a time.
Monday, March 30, 2009
The poor kid was just riding his bike along the street, obeying all the laws, wearing a helmet, going to class. Suddenly a car pulled out from a side street and clipped his back tire, knocking him head over handlebars onto the pavement. As he lay there he saw the car drive away.
Who would do something like that? Accidentally (for I'm almost sure it was a matter of lack of attention) hit a cyclist and then just drive off? What if the kid were seriously injured?
Of course, that's probably exactly what the driver was thinking. "What if I seriously injured that kid? He'll sue me and I'll be paying the rest of my life! I better get out of here!"
The kid walked his ruined bike over to our clinic and presented his shook-up self for evaluation. I was so furious at the negligent driver it was hard to concentrate on the victim of his irresponsibility. The kid did not share my anger. In fact, amazingly, he had experienced the exact same thing before. Another hit and run! He was philosophical about it, and primarily concerned that he'd have to buy a new helmet.
I do try to maintain my faith in the goodness of the human race, and most of the time there is plenty of evidence to support it. But on occasion that faith gets challenged.
Thursday, March 12, 2009
Suffering is when you want the pain to stop. The sentence sprang out at me from the milling sidewalk throng. Ambushed, a part of me spent the rest of the evening struggling in a dark alley. What? How can you have pain without suffering? Aren't they one and the same? Why wouldn't you want pain to stop? Who wants pain?
I remember a Peanuts cartoon from years back. Lucy has to go to the dentist and she's complaining to Charlie Brown. He says to her, "You're not afraid of a little pain, are you?" Her retort is classic. "Of course I am! Pain hurts!"
Goldberg practices Buddhism. Buddhism urges us to look at life honestly, to accept what is. Sometimes life is painful. Everyone knows that. Suffering, by Goldberg's Buddhist definition, is wanting something other than what is. It could be applied to anything. As soon as we start wanting something different from what we have, we are somewhere else. We are distracting ourselves from the present, and the present is the only starting point we have. You've heard the saying, "You can't get there from here?" The truth is, you can't get there from anywhere else. The only way out is through, and the only place to start is here.
So if suffering takes me away from the present, and accepting pain is a way to avoid suffering, I'll accept pain. It's kind of hard to ignore, after all. Accepting pain doesn't mean it won't hurt. But, unlike Lucy, I know that not all that hurts is Bad. Au contraire, in fact. What is beautifully ironic, in my experience, is that the more I allow myself to feel pain, the sooner it passes. The more you hurt, the quicker you heal.
Friday, March 06, 2009
Come into my office, said the boss man to the guy.
The time has come to send you home. Your work is done. Goodbye.
The company is bankrupt: it's chapter seven time.
The doors are locked, the lights are out, we haven't got a dime.
So sorry that there is no pay, no benefits, not one.
We thank you for your time, and know your time has just begun.
Clean out your desk and take your stuff, but leave your sweat and dreams.
We know its bad, but time will tell it's harder than it seems.
You're middle aged. That's life; it can't be helped. We wish you well
with resumes and dusty suits, employment lines from hell.
Now off you go. Get out of here. Go home and tell your wife.
Good luck with that. Leave the keys, and hey - have a nice life.
Saturday, February 28, 2009
There it is...nearly 12,000 ft of intimidation. We were to traverse from bottom to top, as a team. First our biker, pumping 13 miles uphill. Then the runner, with 5 steeper uphill miles. Third, the skier (yours truly) with 2 miles of uphill skiing on skins (it's getting really steep by now). Finally, the snowshoer takes the team colors to the very top of the mountain, a mile of grueling uphill.
As if that weren't enough, the whole team has to turn around and do everything in reverse, top to bottom, ending up back in the town of Grants, NM.
Here's Sue, our intrepid biker, at the beginning of the race.
Sue was followed by Bev, our heroic runner.
Then it was my turn, trying hard here to win the sleeping bag leg of the race.
(Seriously, though, it was COLD waiting 4 1/2 hours up there at 10,000 feet!)
Finally, jaunty Patti (this is before she snowshoed to the top of the mountain and back!)
At the run/ski transition. It's far more organized than it looks! They have it all figured out, and it runs as smoothly as maple syrup in the Spring.
Patti and Peggy after the race.
Patti, Peg and Sue toast our victory - first place women's 50-59 yr old team! Go SHAC Pack!
Wednesday, January 28, 2009
"He fought in Iraq and now he has PTSD." End of story, as if those 4 little letters explain it all. Oh, yes, PTSD. Now we know what he's going through.
I don't believe it. Are all physical wounds the same? Of course not. You wouldn't say, "He had a fracture" and expect his suffering to be explained. There's a big difference between a fractured pinky and a fractured pelvis. You wouldn't say, "She has a flesh wound," and leave it at that. A laceration in the leg is worlds apart from a face half blown off.
Body parts matter when it comes to understanding wounds and healing. In the same way, I think mind parts matter when it comes to wounds of the psyche. I'm not talking necessarily about sections of the brain as an organ, although there is clearly correlation between the two, but about regions of the mind. What part was hurt? What coping pathway was railroaded? What belief system was shattered? What concept of self was blasted to smithereens?
When the body suffers a wound, it helps to know what weapon delivered the damage. What about the mind? What was the weapon, the injuring event, the final blow? We need to know. It helps assess and predict the damage. It makes a difference.
Finally, what about healing? If it is a wound of the body, do we suture? Splint and cast? Perform surgery, even, perhaps, amputate? Do we provide medicine, pills, creams, crutches? Not all treatments are equal, because not all wounds are equal. It's ludricous to think otherwise.
So too wounds of the soul. What kind of healing is right for this crushed confidence? This lacerated faith? This broken, tender self? We can't treat them all the same, with the same drug cocktail, the same kind of therapy, even the same questions. It could be as bad as trying to sew a bone. Ineffective at best, at worst, deadly.
PTSD. The wounds are as individual as the wounded.
P.S. See this blog entry and the associated blog for an eloquent view of PTSD from the inside.
Saturday, January 24, 2009
There are ways and ways to ask patients about their sex life. In med school they taught us the phrase "sexually active." We were supposed to ask the patient, "Are you sexually active?" It sounds silly to me now, but it was presented as Standard Of Care. In other words, everybody does it that way. It was deemed an efficient use of time. One question, cut to the chase.
I even did that for a while, until I realized that many people had no idea what I was talking about. I'd get the blank look far too often, and end up having to ask some other way. Or they'd focus on the "active" part of the question. One of my colleagues got the answer, "Not really. I just lie there." And I heard the opposite extreme when a young man bragged, "Oh yeah! I break condoms all the time!"
So I quit asking it that way. For a while I asked, "Do you have a sex partner?" That seemed to work okay. If they answered in the affirmative, I'd follow with, "Male or female?" and then questions about how long they had been together, whether they used safe sex practices, etc. It took a lot more questions than the one, efficient, "sexually active" query, but it got the job done.
(By the way, we don't say "safe sex" anymore, did you know? Now we're supposed to say "safer sex." Nothing, after all, is 100% safe. Or 100% anything. G-d forbid someone should sue us when they get chlamydia having "safe sex!")
Another of my colleagues tried this one out: "Are you having sex?" Until one of his patients gave him a look and said, "Well, not right NOW!"
The open-ended question is a great way to ask about most things. "Tell me about your back pain," for example. But even I would feel a little weird saying, "Tell me about your sex life" to a patient.
No matter how we ask, there will always be a way to misinterpret it. Some of the medical literature uses the term "sexual debut" for someone's first time. "A woman should have a PAP smear 3 years after her sexual debut." Isn't that priceless? It sounds like there should be a huge party with gauzy dresses and tuxedos. "Introducing the sexual debutantes!"
I finally hit on an opening question that works for me most of the time. "Do you have sex with men, women, both, or neither?" Most people seem to be able to hear that one, and respond without rancor. Interestingly, I have never seen a woman act offended by this question, whether she is straight or gay. On the other hand, quite a few straight men act appalled that I would even consider the idea of them having sex with men. "WOMEN! Only WOMEN!" they huff. I wonder: is homophobia a sex-linked trait?
The other day, I finally got "Neither" in response to my question, which made me realize it isn't quite the catchall I thought it was. Was this a virgin (not as rare as you might think at the university)? Nope. On further questioning, the person revealed that they had in fact had their sexual debut some years earlier but were currently single. No sex for...hmmm lemme think...two whole weeks now!
That brings up another whole arena: sexual definitions. "Monogamy," "long term," "sex;" you'd be surprised at some of the concepts folks have. Fodder for another post.
Friday, January 23, 2009
The Purple Heart is a medal given to those who suffer physical war wounds as a result of enemy action. This medal is not given to those with PTSD. Never has been, even when PTSD was called "battle fatigue." The criteria for the Purple Heart can be seen here:
From that site: A wound is defined as an injury to any part of the body from an outside force or agent sustained under one or more of the conditions listed above A physical lesion is not required, however, the wound for which the award is made must have required treatment by a medical officer and records of medical treatment for wounds or injuries received in action must have been made a matter of official record.
It goes on to specifically exclude PTSD.
Canada has a similar medal, called the Sacrifice Medal, which, interestingly, specifically includes mental injury, as follows:
Eligible cases include but are not limited to...mental disorders that are, based on a review by a qualified mental health care practitioner, directly attributable to a hostile or perceived hostile action.
I'm not convinced that the Sacrifice Medal would cover all cases of PTSD, but it goes farther in that direction than the Purple Heart does.
So how important is a Purple Heart? I've always thought that the Purple Heart was kind of an odd medal. It is often spoken of with awe, as if the recipient did something outrageously heroic. What they did was get injured. Were they heroic? Absolutely. Anyone who puts their life on the line in service to their country is heroic. Even those who did not get injured. Do injured service men and women deserve something more than those who were not injured? Well, yes. I believe they deserve to be treated and cared for, at our expense. Including those with PTSD.
PTSD is a war wound. A wound of the mind, heart and spirit. An invisible wound, yet deeper than any that sheds blood.
We can argue about who gets what medal 'til the cows come home. Frankly, I think they all deserve a hero's medal. But what's more important is that those who need care, whether for wounds of the body or wounds of the mind, get what they need. If this controversy helps bring PTSD to the forefront and gets those guys and gals some help, it's worth it.
Thursday, January 15, 2009
1. In response to a poster who challenged me to work less and write silly poetry more:
Work, I do, I try to heal 'em
Fractures, coughs, sore throats and boils
Rashes, warts and bumps - I feel 'em,
Freeze 'em, drain 'em, coat with oils.
All day long we poke and prod,
Look for clues and try to mend
Some docs even think they're gods
We're always humbled in the end.
Yet, as much as I adore
bedpans, xrays, splints and pills
coughs and sneezes, I want more,
A place to play, to ease my ills
The Forum calls, the poets rhyme,
their sweet abandon, free and wild
with meter foul but words divine
Each silly section makes me smile.
Who knew, when Wondo started it,
this silly thread, that it would be
a testimonial to wit
the best in WD history.
2. Taking a break from "real writing"
I'm s'posed to be writing a column 'bout zits
those mug-ugly bumps that give teenagers fits
How does this thing happen? Please, doctor, help!
I'm spotty, I'm pimply, I'm covered with welts!
It's awful, embarrassing, painful and worse:
My girlfriend won't touch me; she says I am cursed.
So please, give me something to clear my skin up
I beg you, have mercy on this zitty pup!
No problem, I soothe him, the answer is clear
just do what I say, you'll have nothing to fear
Go down to the grocery and ask that new bagger
to loan you a brown paper big one, then stagger
Back home with it over your head! What? My license?
You want it? Oh, what have I done, I have no sense!
I take it all back, I was giddy from deadlines
and trying to be serious: it furrows my head lines
Please calm down, relax now, don't have a conniption
I'll cure you I promise: here is a prescription!
He's gone. Now I have to get back to my writing
Be serious, scholarly, helpful, inviting
Thank goodness for Dread Poets thread- yes indeed
a place to unwind when I'm truly in need.
3. About exotic foods
Pickled eggs I've had, and worse
The thought of frog legs makes me purse
my lips and gag, but I would try
a fresh polk salad, loaf of rye,
some crab legs, sushi (only cooked!
I'm a doc, you know, I looked
beneath the scope, I did, and ugh
what I saw would make a slug
chuck up his breakfast, so no raw
fish for me), a monkey's paw
is taking it too far as well.
I'd like a fondue, that's a smell
that makes me smile, and want to dip
a cube of bread, then take a sip
of Chardonnay, oops there I am
back at wine! alright, then, ham,
but only finest prosciuttos
will make it past my snobby nose
Chinese I'll eat (the food, I mean)
Italian, Spanish, French cuisine
Hillbilly with okra pie
Better than a stick in your eye
But ask me to avoid Whole Foods?
That goes too far, sir, almost rude!
That place is home, my second larder
Quit I won't, I'd fight much harder
For organic foods and fresh ones
even though it uses up funds
Cheap it ain't: just ask Cheapskate
Still its always worth the wait
Don't believe me? Come for dinner
You don't like it? You'll leave thinner
Uh oh, wait a minute, what's this?
I can't stop creating bupkiss
Rhyme's Disease has taken over
Get the hook! I'm done! It's over.