THE FAILURE OF MENTAL HEALTH TREATMENT: THE DIVORCE OF PSYCHIATRY AND PSYCHOTHERAPY

There is a massive problem with the practice of psychiatry in today’s modern healthcare industry. There are several reasons for this, which I will address in a moment, but first, let’s get a few things out of the way.

Many people have a very reactionary, negative opinion of the field of psychiatry. They feel that it does more harm than good. In today’s healthcare environment, they may have a point, but I am speaking in general terms. Psychiatry, to many, is a dangerous science that can damage your brain. Of course; many medical procedures can damage you if administered improperly. That’s why I went to school. Many people feel that psychiatrists have very little clue as to what they are doing. While it is true that the study of the brain, which has remained a difficult and emerging science for a very long time, and will continue to be so, there are millions of Americans who have benefited from what psychiatry does know, and what treatments it can provide. And still others feel as though psychiatry, and indeed, any treatment of the mind or emotions, should be out of the realm of medicine, and kept in either the family or church. While it is very true, and studies have confirmed this, that those of faith, or at least some level of healthy optimism about life, tend to heal much quicker from whatever affliction they may have, that does not mean that medical intervention is sometimes required. Nor does it mean that atheists do not heal.

Plenty of people have a negative opinion of healthcare in general. That is unfortunate. Many millions of people have benefited from the proper treatment of an affliction, and go on to live healthy and productive lives, despite an illness that would have been a death sentence one hundred years ago. The human body is a machine, an amazing construction, the triumph of life on Earth (although the debate about that is for another time). Whether by evolution or design, you and I, and everyone else on Earth, are amazing creatures, composed of practically countless processes, organs, chemical and electrical reactions, and things still yet to be discovered. However, just like any other form of life, like any artificial machine, like any magnificent creation of geology, things can, quite simply put, break down. Sooner or later, it happens to all of us. Have you ever thrown your back out? Well, so have 65 million other Americans. We are wondrous creations, but not entirely perfect. Healthcare plays a role in our repair, and improving our quality of life.

But back to psychiatry. The negative connotations I mentioned above are not entirely unfounded. The history of psychiatry is replete with practices that today seem barbaric, and would never be considered as an option for treatment. What is worse, in modern history, authoritarian regimes have tortured and killed untold numbers under the guise of psychiatry: Nazi Germany, The Soviet Union; even the CIA is guilty of using psychiatry for nefarious purposes.

However, like all healthcare, psychiatry is an evolving field. Healthcare, in essence, is an applied science. That is, it is a scientific endeavor, used for practical means. Many constructive gains have been made. However, the application of these discoveries, when applied to the practice of modern American healthcare, has been severely misappropriated.

I can’t get into the tired debate of whether or not mental illness exists. Believe what you will. Many people, intelligent people, will claim that there is no definitive diagnostic test to prove whether or not a mental illness exists. It is true that nearly all mental illnesses, particularly the behavioral ones, are diagnosed by interview and observation, or that form you occasionally fill out at your annual exam where you check the corresponding box as to whether you are happy or sad. However, you can get out the fancy medical equipment and see it for yourself. In people with anxiety, a part of the brain called the amygdala is overactive. In cases of depression, insufficient monoamines are developed in the neurons of the brain. One could utilize these ludicrously expensive machines if you want to see the proof, but good luck getting insurance to pay for this.

Mental illness exists. I was once speaking to a friend of mine, who had a negative opinion of psychiatry, and said to just get that person with depression some dancing lessons, a cat, and an exercise program. Okay, Tom Cruise. You tell the guy with the gashes in his wrists who’s hanging from a noose to get some dancing lessons, B-vitamins, and some duct tape, and I’m sure he’ll be fine. Sheesh. But I needn’t be snide. Annually, roughly 49,000 Americans take their lives each year. Suicide is the 10th leading cause of death in the United States; however, it is the second leading cause of death for those between the ages of 15 to 34. There are, on average, 132 suicides per day. Perhaps worst of all, according to the Department of Veterans Affairs, 20 veterans die from suicide every day.

To be fair, engaging in activities that one enjoys that are healthy, socializing with others, becoming involved in a community art or political program; these are great ways to alleviate the symptoms of depression. So too with the natural remedies; regular exercise, a healthy lifestyle, artistic expression, prayer and faith, whatever you might like. But many people are too depressed to even get out of bed.

Besides depression, anxiety disorders are the most common psychiatric disorder in the United States. They affect 40 million people. Untreated, this illness will damage those around the afflicted, cost industry labor, and overburden the healthcare industry. People having panic attacks often end up in the emergency room. The number of those with anxiety disorders is no doubt growing, considering the trauma of the last year and a half.

And we’re not even talking about schizophrenia, ADHD, PTSD, bipolar disorder, panic disorder, and a host of others. Intelligent people with fancy degrees will argue that the DSM, the Diagnostic and Statistic Manual of Mental Disorders, is cluttered with debatable mental disorders. It contains nearly 300 diagnostic entries. It should be noted that the ICD, the International Classification of Diseases, contains about 80,000 entries.

But I am severely digressing. The main point I am getting at with this article is the unfortunate practice of psychiatry that one will often encounter when they visit their regular clinic or provider.

Somewhere along the way, a great disservice was done to the field of mental health. Psychiatry and psychology were divorced. This is profoundly wrong, and does not do nearly enough to heal the mentally and emotionally afflicted.

These two sciences, psychiatry and behavioral psychology, go hand in hand. They are deeply intertwined. You cannot simply address psychiatric needs while at the same time giving little consideration, or even downright ignoring, the psychology that goes along with psychiatric suffering. It is analogous to a physician simply giving a person with diabetes insulin, and telling them to monitor their blood sugar at home, while not counseling them on their dietary habits. So with psychiatry. You cannot simply throw pills at them, without addressing the psychology, usually damaged, that accompanies it. This makes no sense.

Unfortunately, that is the solution of much of modern healthcare: throw a pill at it. Also, due to the profit motive, patients are generally allotted 15 to 20 minutes for a visit with a healthcare provider. That is not enough time. The psychiatrist, or MD with a specialty in psychiatry, may ask them how they’re feeling, how’s the job, etc, but that is insufficient time to dig deep enough to treat the illness.

Psychotherapists exist, of course. However, they are harder to find, as insurance will still balk at their treatment, or they are booked far in advance due to the dire need, owing to the stressful times we live in.

Some clinics will not even have a dedicated psychiatrist. Your primary care physician will treat you. I’m sure that person cares about their patients, and has studied, at whatever length, both psychiatry and psychology, but they are much more likely to just throw pills at you, tell you to keep a journal or do some art or something, and come back and see them in a month.

I was diagnosed with a mental illness in my early 20’s. It should be noted that there is no ‘cure’ per se, but there are treatments to alleviate the symptoms, mental exercises to retrain your thinking, so to go on and live a healthy and happy life. I was able to do so. Despite a crippling depression, in a way, I was very fortunate. I was first treated by a seasoned psychiatrist, whom I called Dr. Dispensapill, who knew that psychiatry and psychology cannot be separated. He would see me for an hour. We would talk briefly about medications. Then we spend the bulk of the visit speaking about psychological challenges I might be facing. Then we would wrap it up with any medication or lifestyle changes to consider.

His is a disappearing style. You can still find psychiatrists like him, but they are rarely covered by insurance, and they are frequently booked far out.

Dr. Dispensapill, north of 80 years old, recently ceased being able to practice. It was difficult to find help for my mental health afterwards, but I have found a combination that works. I see, for 15 minutes at a time every few weeks, Dr. Deer In The Headlights, who knows little of psychotherapy, it seems, but knows all about the different medications and how they work. She got a 4.0 in advanced chemistry, I guess. I have also been able to find a very skilled psychotherapist, Dr. How Many PhD’s Does One Actually Need. She has been fantastic.

More than one of the providers that I work with have complained to their superiors that there is a woefully insufficient staff of human resources to refer psychiatric and deeply troubled psychological patients to. They will help the best they can, but they are there to treat skin rashes and broken bones.

This is a great problem in American healthcare. We have made a damaging mistake. The mentally ill are not getting the proper treatment that they so often need. The separation of psychiatry and psychology is, in my low-level practitioner opinion, the biggest systemic mistake modern American healthcare has made. You can’t treat one without treating the other, and vice versa.

Until we fix this problem, and there are other, massive problems with American healthcare, the treatment of the mentally ill will remain insufficient. Many more will take their lives. Millions will continue to be crippled with anxiety, living tortuous lives. And the dangerously mentally ill, with no options for treatment, will continue to commit violence.

I’m not sure why this happened. It shouldn’t have. Just my opinion.

Be good to each other.

National suicide hot-line: 800-273-8255

CRACKING THE GLASS CEILING: I AM A MALE MEDICAL ASSISTANT

In early 2020, when I walked into class for the first time to train as a Medical Assistant, an obvious truth was right in front of me, so evident; but I did not notice. I had been painfully preoccupied with all the preparations required for going back to school. When you are doing it on your own at age 47, trying to also balance a life and another job, it takes all your time: the paperwork, the vaccinations you need, the textbooks you must purchase (at a very reasonable price….), the equipment you need, where you have to go, that sort of thing. But I had squared all these things away. I was ready to learn.

I was admittedly overwhelmed by my surprising mid-life crisis to enter healthcare. I had read through the aforementioned, completely reasonably priced textbook before class started. It was over 1000 pages, and that little voice in the back of my head, the one that still nags at me when I go to work, though much quieter now, was at full volume: What the hell are you doing! But on January 7th, 2020, into class I went.

I am a shy person by nature, and was still overwhelmed and nervous, so I saw a few of my classmates (we were a class of nine to begin with, and a few of us were already there), nodded my head, tried to smile, and took a seat.

The first few days were chaotic. Our program was a hybrid learning system, with in class lectures and clinical training, and at-home, online training modules. My opinion of the online training modules is still not settled. The jury is still out. More on that later. But we all had to learn how to log into the school’s system, we all had to make sure we had all the right equipment and uniforms (I had the wrong color scrubs… more on my instructor in a moment), and all of us, including myself, had endless questions. My instructor patiently addressed all of our concerns, but this chaotic orientation process took a few days.

As things settled down, and I began to learn, I was fascinated by my new decision. I knew I had made the right choice. My instructor was a seasoned Medical Assistant, impeccably dressed, with perfect hair, named Jason. I’m a confident heterosexual, and I have no problem with anyone’s orientation, but Jason was a fine looking man. Sometimes I wondered…. he must have had to get up at four in the morning to work on that hair. Perfect hair, always.

By the second week, we were splitting off into small groups. I got to know my classmates more and more, an interesting bunch. We were all older than your classic college students, all coming from careers that had driven us to make a change. There was Fairahn, a demure American Muslim woman who turned out to be smarter than she thought, gaining confidence; there was Teri, a beautiful woman who always looked like she was about to kill someone; there was Jane, who I never quite figured out; there was Joni, a busy mother who struggled at first but turned into one of our best students; there was Janet, a CNA looking to advance, and was a seriously ineffable person, that I still struggle to figure out; and there was Helen, who had a resting bitch-face that could make a honey badger back off.

Wait a minute, I thought. I’m the only male.

I had no problem with that. Perhaps that was just the way the dice rolled. I certainly did not dwell on it; I’ve always believed that women were just as capable of doing any job that a man could do, and vice-versa. The difference is when it comes to reproduction, but vocationally, I’m glad that women are slowly breaking the glass ceiling: the US military, construction, IT, and now a female Vice-President. We would have had a female President in 2016, (I imagine things would be quite different now), except for that Pact with Hell known as the Electoral College. But I digress; I don’t like to talk politics here.

Like I said, it didn’t bother me, at all, that I was the only male student. One day, after class, I asked my instructor about this, and he replied that the field of Medical Assistant is definitely a female-dominated industry.

He wasn’t kidding: https://datausa.io/profile/cip/medical-assistant#demographics

93% of all Medical Assistants in the United States are female.

I have searched all over this unwieldy behemoth known as the internet, and I have asked professionals, as to why this is. There does not seem to be a concrete answer, other than the time-honored tradition of gender stereotyping. Which needs to stop. And in healthcare, it slowly is.

The fact that I was the only male in my class never bothered me at all. I was raised by progressive parents, and, as I mentioned, the glass ceiling needs to shatter.

But it shatters slowly. In the United States, 3.5% of firefighters are female. 39.9% of financial analysts are female. Women make up 9.9% of the construction industry. 19% of software developers are women.

There are dangers to ‘gendered’ jobs: https://www.businessnewsdaily.com/10085-male-female-dominated-jobs.html

When one Googles the question: What is a male nurse called? (this actually happens), the answer comes up: nurse. Among the more conservative elements of our society, labeling a job as ‘female’ can diminish its authority. There are financial dangers as well. Female Medical Assistants, on average, make about 88% of what their male colleagues do, and men are more likely to be promoted. This pay discrepancy is in no way isolated in healthcare; on average, across America, women earn 82 cents for every dollar a man earns: https://blog.dol.gov/2021/03/19/5-facts-about-the-state-of-the-gender-pay-gap#:~:text=1.,for%20many%20women%20of%20color.

But it was never an issue in my class; we all became friends, a team, and the fact that I was male never became an issue. We all had a group text-chat, and kept in close touch when we were out of school. Remember that at-home, online learning? If one of us was stuck, no problem. Text the gang!

I became great friends with the class alpha, Helen. She was the one with the resting bitch face that could stop the blast effect of a nuclear weapon. Our gender differences were never an issue. There was no sexual tension; we were two dedicated students who wanted to do our best. As our school year went on, and we were presented with harder challenges, some quite unexpected, we backed each other up. She was the Furiosa to my Max; two people who found themselves in a difficult situation, and supported each other to get through. Fury Road. Brilliant film. Anyway…

What I have noticed in healthcare is that nearly all of the supportive roles, from CNA up to ARNP, are predominately female. However, with MD’s, the glass ceiling is breaking quickly. I have worked and met many female physicians. Each one capable, each according to their gifts.

My own feeling is this: the gender stereotyping is hard-wired into society’s heads, and has probably been around for a very long time. I know nothing of anthropology, but, at the risk of oversimplifying things, a very long time ago, men were expected to go out and hunt, and protect the tribe, while women were expected to tend to the village and care for the young. This evolution continued into the modern age; where men do the hearty, rough, dangerous things, with unnecessarily large pickup trucks, while women are expected to keep the house and raise the children. But it doesn’t work like that anymore, it can’t. To make ends meet, both partners need to work, and hell, any female can use a firearm, be an astronaut, or a member of Congress. Why, just look at Marjorie Taylor…. Eh. Very poor example.

I have never encountered it, but there can be gender discrimination against males in the Medical Assistant vocation. Many male MA’s are not taken seriously by deeply conservative patients, doctors, and the general public. Men in this role are more often perceived as effeminate or otherwise inadequately masculine (me? No on the former, definitely on the latter). This discrimination could possibly be due to the concept that men are not adequate caretakers. What a load of BS!

https://www.medicalassistantcareerguide.com/gender-discrimination/

On the other hand, many patients can feel more comfortable with a male Medical Assistant, especially male patients. If the patient has a deeply personal problem, they may find it easier to relate to another male.

Though I have experienced no discrimination of my own, and I have never been treated differently because I am a male Medical Assistant, the problem continues in our society at large. Women are just as capable as men, and should be treated not just as equals, but simply fellow human beings. The glass ceiling has many cracks, but our society still has a long way to go.

So I’ll go to work some day, surrounded by estrogen. It doesn’t bother me at all. I’m here to be the best Medical Assistant I can be. If all of my coworkers are female, so be it. As long as you’re cool and can do the job well, preferably the former, you’re okay in my book. I’ve found that it gives me a different perspective, to experience the female side of society. But that is secondary. I need to learn how to find the damn vein for venipuncture, first. And if a female Medical Assistant helps me with a blood draw, I have no problem with that at all.

EMPATHY FOR THE SUFFERING: ANOTHER DAY AT WORK

“Everyone you meet is fighting a battle you know nothing about. Be kind. Always” -Robin Williams

In my first week of Medical Assistant training school, three concepts were drilled into our heads. They continued to be imperatives throughout the entire academic year, and are expected to be applied in an actual working environment.

The first two are related, and immensely important in stopping the spread of illness. Healthcare facilities are hotbeds of disease, naturally, so these commandments must always be followed. The first two are: medical asepsis and the Standard Precautions. Medical asepsis (a: against, sepsis: the presence of dangerous microorganisms) means keeping your work environment as clean as possible, as well as yourself. These tie in with the CDC’s Standard Precautions: hand hygiene, the use of PPE, sharps safety, sterile instruments and devices, and more.

A brief note on washing your hands: this is the single best invention of healthcare, and one of the most crucial. Here, in the Covid Age, it is vital.

The third concept that is hammered into a Medical Assistant student’s head is more abstract, and extremely crucial in healthcare: the concept of empathy. It is human nature to judge, that cannot be avoided. But empathy requires one to understand the feelings of another, and, in the case of healthcare, to do our best to understand the ill and injured, and the suffering that has come upon them. We never judge. We are not concerned with what brought a patient to this condition, only how we can help them going forward. We do our best to heal, and to educate the patient so that this does not happen again. If the patient is truly damaged, be it from drug use, diabetes, or mental illness, there is an army of healthcare professionals that we will refer them to.

Believe it or not, when a patient leaves the facility, the empathy continues. We do not laugh and make fun of a potentially embarrassing condition. We do not judge behind the patient’s back. None of us do. In fact, in all of my work experience, we express pity, sadness that someone is going through life suffering. It is heartbreaking. Healthcare is not a job for the thin-skinned.

To be clear, we cannot sympathize, only empathize. To show empathy is to acknowledge another person’s feelings. It requires the emotional component of truly understanding, to the best of your ability, what the patient is feeling. You do not share these feelings yourself, but you understand the emotions the patient may be experiencing. Sympathy, on the other hand, means to share what the patient is going through, and to feel the emotions yourself. In healthcare, you cannot do that. You truly do not know the patient’s entire story, even though you learn much about them. You cannot sympathize, and present yourself as someone who shares the same suffering.

The concept of empathy is difficult to be taught in a training program. It is beneficial to be born and raised with this quality. How it it taught in a program is to simply learn about the illnesses and diseases, the suffering of the people you will eventually meet. Once a student understands what they will experience in the working world, the empathy starts to take hold.

During my training, when I learned about the legion of things that can wrong with the human body, my empathy grew stronger. Each of us in our own way is broken. Early on in my program, it gradually dawned on me what I would be doing and encountering on a daily basis. When I was much younger, college did not work out for me. But at the tender age of 47, making a bold career change later in life, I intended to take my studies seriously. I devoured the material. All of it fascinated me, and I knew I had made the right decision. It paid off, sure, with good grades and all, but school cannot prepare you for what you will actually see. I did understand there was no margin for error. In many vocations, if you make a mistake, it can be corrected, and the boss will yell at you. In healthcare, if you will pardon my drama, making a mistake can cause a patient serious harm, or worse. But my empathy gradually grew more into a sense of compassion; a desire to help others. It continued to grow.

I am very fortunate, in a way. I had found a job I love, in a field that continues to fascinate me. I have a job and a hobby at the same time. The human body is an amazing machine.

In 2021 I lost my father, just a few weeks shy of his 93rd birthday. A close family member was dealing with their own, ruthless demons. And I myself had grown somewhat despondent, as my licensing process (that’s a whole ‘nother story… every healthcare worker needs to be licensed by the Washing State Department of Health… usually a 1 or 2 week process, but in the Covid Age, mine took 3 months), and I wondered if anyone would hire a brand new MA like myself. But in a way, this strengthened my empathy, and my desire to help others, as you cannot give up on others if give up on yourself.

Then, I was extremely fortunate, and found work at a fantastic clinic. I was eager to get started, but a new MA is kept on a very short leash. But from the first day, I understood what my instructor was trying to subtly tell us, as he taught us the myriad of ways that a human being can suffer. I saw it first hand, the first day on the job, and I see it everyday, something new, something heartbreaking. I understood what my instructor meant when he spoke of empathy. The amount of suffering in the world, and the amount of people that need help, is truly staggering.

To be sure, much of what I see is fairly pedestrian to healthcare. A bad back, a sore shoulder, a nagging flu. They may be nuts and bolts to healthcare, but that does not mean the patient is not suffering and in need of help.

But much of what I have seen is truly heartbreaking. My personal emotional armor quickly developed, a necessity in healthcare. The suffering I see is my job. I signed up for it. And again, all of us feel for the afflicted. We do not mock the patient when he or she leaves. We acknowledge that we are saddened by what we have seen, and this inspires us to do more to help. All the while, your personal emotional armor must remain strong, or you will break. If you don’t have this mindset, you can’t work in healthcare.

One thing to consider: I work in a family medicine clinic. If a patient is beyond our clinic’s ability to treat, we refer them to a specialist; a cardiologist, a psychiatrist, an endocrinologist. There are those in healthcare who work in emergency departments, intensive care units, and Covid wards. The suffering I encounter does not hold a candle to theirs.

I have seen many things, horrible and fascinating things, in my new career. I have many stories to tell. I must hedge my words a bit. There is a law known as HIPAA (that’s for another time) that precludes me from offering specifics of a patient’s suffering outside of the workplace. So bear with me as I relate.

Healthcare has a habit of using fancy words for everything. If you have wax buildup in your ears, they need cleaning. But of course, this is known as impacted cerumen, treated with a lavage. There are several methods to this process, but the old tried and true is fill a spray bottle with warm water, loosen up that crap, and scoop it on out with a narrow probe. Oftentimes, and by that I mean all the time, the patient does not care for this. I operate as gently as I can, but that stuff has to come out! I use an instrument called an otoscope, and peer into the patient’s ear. Look at all that crap! Let’s get it out of there! A small container is held under the patient’s ear. As I spray, and the patient continues to look woozy and uncomfortable, the water drains from the ear…. full of unspeakable, horrible things. I peer with the otoscope again. Well! More gold to mine in that vein! Then comes the probe. You have to carefully get it in there (there’s fragile stuff in there), and scoop it on out. When I am finished, I try not to show them what I have removed, but they often see. I’ve seen patients gag. But hey, you can hear better now, right?

There is a common parasite called a tapeworm. It often strikes the very young, as they spend much of their time at day-care, or, as I like to call it, the plague palace. Well, the tapeworm likes to live in the intestines, and the colon, feeding off of whatever your digestive system is done with. I have assisted with the removal of a tapeworm. I will spare you the details of how this is accomplished. But again, empathy. Disgusting, yes, but I felt bad for the young patient.

I have not been working long, but I have assisted with circumcisions. The physician does the work, while I hand them instruments, adjust the light, and help hold instruments in place while the physician works. You can film your child’s birth. Sure. But I’m not certain you’d really want to film this process.

Most of the time, an abscess or a boil can be treated with antibiotics. Not always. The physician will inject a small amount of lidocaine (a numbing agent) near (or in… ugh…) the infection. The patient does not always take this well. However, once the area is numb, the physician can get to work. A small incision is made, and depending on the type of infection, it is allowed to drain. Sometimes it drains a lot. Never look these up on YouTube. Trust me. I hold the light for physician, and wipe away the drainage. There is a reason healthcare goes through so many gloves.

But it’s not all fun and games. Some of the worst injuries are ones you cannot see. This is where empathy is the most strongly required.

I was rooming a young person for a relatively simple procedure. The physician had checked this patient’s chart notes before the visit, something we both do, and something triggered in the physician’s mind to check this patient’s blood sugar. Before finishing up with the patient’s rooming, I checked their blood sugar. The glucometer read 300. Something must be wrong, I thought. I ran the test again. 300. I quickly finished up, and went to speak to the provider. The physician told me bring an A1C test, a test that measures blood sugar levels over the last 3 months, while she was with them. I took the sample, made my way to the lab, and secured the A1C results after running the test. I sent a private chat message to the physician, still in the exam room. She asked me to call in another physician. The poor patient had come in for a simple procedure. They left with a possible diagnosis of Type I Diabetes, a life-changing event.

I was rooming a patient once, who had come in for test results on their lungs. In my station, I am forbidden from telling the patient their diagnosis; it’s a bit above my pay-grade. But I could see the notes in the system: three malignant tumors on the patient’s lungs. They wanted to know the results. “Just tell me!” I knew what I was looking at. They did not have long for this world. I apologized, and told them the physician would be right with them.

Perhaps the most heartbreaking, hidden wounds that I cannot see, but I experience nonetheless, are those with mental health issues. In my short time, it has been shocking to see how many people are emotionally hurting. Granted, the Covid Age has inflicted damage on all us, in some way, but I had no idea it was so rampant. Often, I am asked to enter the physician’s notes, after the patient’s visit, concerning their mental health. My emotional armor is growing stronger, but I am still a human being. Some of the notes I enter are quite sad. I remember glancing at the patient’s age once. A young teen. Just a child, really, with dire mental health issues, and a hard life ahead of them.

However, myself and everyone I work with are drawn to heal and help others. We do our absolute best to heal the suffering, the pain that is so rampant. We want you to get better. We will do everything we can. But this is why you see videos of doctors and nurses, just finishing six days of twelve hour shifts, burned out and beaten up, sharing their stories, sacrificing so much to try, in their own way, to make the world a better place. One patient at a time.

But it is difficult work. There will always be suffering. And empathy will always be required.

ARE YOU BROKEN? PROBABLY. DON’T WORRY, THERE’S A CODE FOR THAT!

Well, let’s take another look under the hood of healthcare.

Healthcare, the practice thereof, confuses many people. That’s understandable. I wish that I had more time to explain to my patients what I was doing, because it’s incredible stuff. Another thing that confuses many people is health insurance. In fact, it makes them quite angry. Understandably. But that leads to my next topic. Let’s confuse things even more with the riddle of modern healthcare that is billing and coding.

In a moment, we’ll take a look at the ICD. But first, some context. Just about everything that happens in healthcare has a number attached to it. It’s really more simple than it sounds, but here we go: HCPCS (Healthcare Common Procedural Coding System) was established by the Centers for Medicare and Medicaid Services in 1978. Though it is in the purview of the CMS, it applies to all healthcare coding. There are three levels to it, but the first level is the most common, and it contains what are called CPT codes, or Current Procedure Terminology codes. These are the codes for what the physician does to you: evaluation, surgery, lab work, prescriptions, tells you to lay of the bacon cheeseburgers, etc. Pretty straight forward.

Then there are the ICD codes, or International Classification of Diseases. These are the codes for what exactly is wrong with you, and why you came to see the Doctor in the first place. A broken arm has a code. A flu has a code. A dog bite has a code.

Ostensibly, the ICD codes were implemented to track diseases across a population. Since illness has no respect for political boundaries, these codes are also used to communicate to physicians across the planet. Researchers and physicians who may not speak English can at least decipher the ICD code.

This concept has been around for a long time. Some medical historians place the origin of the ICD codes as far back as 1763, when a French physician named François Bossier de Sauvages de Lacroix developed a classification of 2400 diseases. (https://pubmed.ncbi.nlm.nih.gov/20978452/) The list continued to grow and develop, and by 1898, the United States was using the International List of Causes of Death. (https://pubmed.ncbi.nlm.nih.gov/9082128/). More twists and turns of the list followed, until the establishment of the United Nations and its subsequent organizations.

In 1948, the World Health Organization took over the ICD listing. The various lists used across the world were compiled, and the first official list, number 6, was published in 1949.

Again, these codes are used to track illnesses across populations and for better communication between the healthcare infrastructure of nations. However, these codes have taken on another role. These are the codes that are sent to insurance companies when a facility needs authorization for treatment, along with the CPT code mentioned above. The insurance company will plunk these codes into their computer, mull in over, and respond with how much they will cover, which 11 times out of 10 is slightly south of zero.

In my training, I was taught to look up ICD codes the old fashioned way. Our instructor handed us each a large book, the latest ICD code book, with more pages than War and Peace in large print, and we were to track down a patient’s ailment. These days, the code is simply generated when I enter it into the computer. If I enter ‘back pain,’ the code is automatically generated, with the option for further detail, should the physician think it warranted. My instructor loved to make us work for it.

Bear in mind, the ICD code book is not to be confused with the Diagnostic and Statistical Manual of Mental Disorders. That’s a whole different list of problems. I’ve got about half of them. Work is underway to integrate the DSM with the ICD, but that will probably take some time.

In 1979, the ICD-9 was published. The codes are alphanumeric, five -seven digits long, and have the option for modifiers. There were over 13,000 different codes.

In 2015, the United States adopted the ICD-10. It was greatly expanded: there are over 70,000 different codes.

The theory was, the massive increase in entries allowed for greater specificity of the ailment, and did away with the need for modifiers. You ask me, someone had a little too much time on their hands, and probably started the day a great big bowl of amphetamine flakes. Nom nom!

Yeah, the ICD-10 may have taken it a little too far. The following are actual entries from the massive list:

W61.33: Pecked by a chicken

W5921: Bitten by turtle

R46.1: Bizarre personal appearance (Oh, I got that one, for sure…)

Z63.1: Problems in relationship with in-laws (What? When does that ever happen?)

V97.33: Sucked into jet engine

R15.2: Fecal urgency

Y92.253: Injured at Opera House (Hey, it happens…. Over 6 people a year succumb to this tragedy)

Y92.241: Hurt at the library

Y92.146: Swimming-pool of prison as the place of occurrence of the external cause of injury

Y93.D1: Stabbed while crocheting

V9107XA : Burn due to water-skis on fire, subsequent encounter (I really don’t know what to say…)

V9542XA: Spacecraft collision injuring occupant (Eyes front, Major Tom!)

And my personal favorite: Y.34: Unspecified event, undetermined intent (Well, sure! That works!)

I’m making none of these up. The ICD-11 is set to published in 2022. It is said to be almost five times as large as the ICD-10.

To end on a serious note: occasionally, the ICD will need to be quickly amended. In April of 2020, a new code was added. U07.1: Covid-19.

Wash your hands! Social distance! Wear a mask! Get vaccinated! Avoid Florida! We’re not through this yet!

The Death of My Father and the Five Stages of Grief

 

February 12th, 1PM, 2021

I finally get to see my dying father. He and my mother have been living in an assisted living facility for several years, and when the Covid-19 lock-downs began, all visitations were suspended in March of 2020. They persist today. I haven’t been able to give either of them a hug for a very long time. As my father has had several recent strokes, and his health and cognition have declined, it has been very difficult, emotionally painful, not being able to see him. He went from the hospital back to the assisted living facility. I could not visit him. But today, as he is now officially in palliative care, the facility has made special arrangements and provisions for me and my family to see him. It was hard to knock on their apartment’s door, as I knew what was coming. But, as she greeted me, I hugged my mother today for the first time in almost a year. And then I saw my father.

In 1969, Swiss-American psychologist Elisabeth Kübler-Ross published a book called: On Death and Dying. Kübler-Ross had made created a devoted career to caring for and treating the helpless. She began her career as a psychiatric resident at the Manhattan State Hospital, working with patients that modern healthcare of the time had all but cast aside; the schizophrenic and what were called ‘hopeless patients,’ a delightful little reference for those with a terminal illness. Kübler-Ross was shocked by the treatment of mentally ill patients and those that were given no hope of recovery. The compassion this instilled in her would define her professional career.

There was my father. The palliative care division of the hospital had set up a hospital bed, with the oxygen tanks and the monitors stashed in the corner. Neither were hooked up. I looked at the man lying on the bed. This powerful man, this strong yet caring, sensitive, and compassionate man, lay dying before me, withering away, one foot already in the world to come. His skin was blotchy and pale. His breathing was shallow and irregular; I knew this to be Cheyne-Stokes respiration. His hair was unkempt, his beard was a tangled mess of whiskers. At death’s door, here was my disheveled father, his body rapidly giving out.

In 1965, Kübler-Ross became an instructor at the University of Chicago’s Pritzker School of Medicine.

She continued her work with terminally ill patients. Motivated by the lack of instruction in medical schools on the subject of death and dying, her research progressed into a series of seminars with her research and interviews with terminally ill patients. In 1969, she published her famous work, On Death and Dying.

I sit on the edge of the bed, and gently grasp my father’s hand. His glassy eyes come to life for a moment, and focus on me. I ask him how he is feeling. There are words, mumbles that take great effort to come from him, but they do not make sense. I tell him that he has been a wonderful father. I tell him that all he has taught me about life; compassion, reverence for all living creatures, a calm sense of humor, and a passion to learn more. I tell him that this is the best inheritance I could have, and that I am very lucky to have been his son. His face remains expressionless, and yet a I see tear forming in his right eye. His recent strokes had caused him to have problems with his vision. Or maybe this shedding of a single tear was a goodbye.

Sadly, the history of healthcare is replete with horrific, barbarous treatment of the mentally ill. Every so often, someone like Kübler-Ross will shift the paradigm, and the mindset of not only the medical community, but society at large, will begin to change. Kübler-Ross’s work with not only the deeply mentally ill, but those who faced a terminal illness, was rather groundbreaking for the time. She was greatly motivated by the lack of instruction in medical schools on death and dying. Feelings, emotions. You can’t measure them. You can’t see them. Yet they are there, and how a person faces death is one of the most powerful challenges a person can experience.

I lean down and give my father a hug, though his arms cannot embrace me. I tell him that he has been a fantastic father. Though he already had one foot in the world to come, he strained to speak something he has always said whenever I express my love or gratitude for him. Though he labors to speak, I hear him, barely: “Oh, I’ll do in a pinch.” Perhaps part of his brain was still working and that response was purely reflex. Or perhaps some part of his soul understood me, appreciated what I had said, and was doing its best to say goodbye.

In her book, Kübler-Ross describes five terms, or steps, that a terminally ill patient may go through when faced with a deadly diagnosis. Over time, her process has grown to include not only those that are dying, but anyone who is facing loss or grief of any kind. The acronym is commonly know as ‘DABDA,’ and were originally outlined as follows:

1) Denial

2) Anger

3) Bargaining

4) Depression

5) Acceptance

Of course, no model of human behavior is perfect and scientifically predictable. The human brain remains a great mystery, and human psychology even more so. Some may experience part of these phases, some may go back and forth, and some may experience only one or two. Examples of such, perhaps imagining that a patient has been diagnosed with terminal cancer, may go something like this:

1) Denial: “That’s impossible. That diagnosis must be wrong. There’s no way in hell I could get cancer.”

2) Anger: “Why me? How could this happen? Who do I blame?!?”

3)Bargaining: “I know if I just change this part of my lifestyle, I could actually beat this thing!”

4) Depression: “I’m going to die soon, What’s the point?” The individual has recognized their mortality.

5) Acceptance: “I can’t fight it. I will accept it. I will prepare for it as best as I can.” A calm, stable emotional acceptance may come over the afflicted.

As I mentioned, this model can apply to anyone facing a grief or a tragic situation; the death of a loved one, the loss of a job, the loss of a relationship, the loss of a pet; any situation that involves loss that one has no power or control over. A fantastic example is from a book by writer David Kessler, who worked extensively with Kübler-Ross leading up to her death. Regarding this damned virus that has ravaged our world and has kept me some seeing my father wither away, Kessler writes:

“There’s denial, which we saw a lot of early on: This virus won’t affect us. There’s anger: You’re making me stay home and taking away my activities. There’s bargaining: Okay, if I social distance for two weeks everything will be better, right? There’s sadness: I don’t know when this will end. And finally there’s acceptance. This is happening; I have to figure out how to proceed. Acceptance, as you might imagine, is where the power lies. We find control in acceptance. I can wash my hands. I can keep a safe distance. I can learn how to work virtually.”

My eyes meet my father’s for one last time. Though he may not be able to see it through my surgical mask, I am smiling a goodbye. His eyes, though glassy and crusted with rheum, blink at me. Perhaps the best goodbye he say. I turn and leave his bedroom, looking back at my father one more time, and enter the living room. I embrace my mother and cry.

Everyone grieves differently; as I indicated earlier. One might feel one or all of Kübler-Ross’s stages. Or perhaps none at all. Kübler-Ross’s work was important and seminal. Since her work, psychologists, the healthcare industry, and society at large (to a degree) have been more open to talking about, researching, and sharing their experiences on death; for it is not the end of life, but a part of it.

I sit in a chair in the living room, exhausted. My mother brings me a cup of coffee, and takes a seat herself. I have compiled what I call a ‘Dad-List,’ a listing of tasks that need to be taken care of when someone dies. There’s a long list of people, friends and distant relatives, that need to know. Social Security needs to know. Dad’s teacher’s union pension needs to know. The credit union needs to know. And through it all, you have to find some way to grieve.

Not to pile on the psychology 101, but there are many defense mechanisms a person will use when confronted with difficult circumstances or behaviors. My ‘Dad-List,’ though an important part of this process, is an example of intellectualization. With this mechanism, a person uses reasoning to avoid confronting emotional conflicts and stressful situations. A person might focus on details and logistics, important though they may be, instead of allowing themselves to feel the grief and despair.

I set my Dad-List off to the side. My mother and I share a long conversation. Both of us take turns bringing up the many wonderful memories we’ve had with my father. Though he still alive in the adjacent room, both of us speak as if he is gone. We know the time is short. But there are so many wonderful memories. It’s almost like we’re trying to keep him alive, by pushing the positive, and not talking of the decaying husk lying in the next room, struggling to breath its last.

I have a great phone conversation with my psychiatrist, Dr. Dispensapill, when I get home. We talk about grieving, and what I might expect when my father finally goes. He has been a great help to me; he has helped me overcome both a crippling anxiety and depression disorder, and, unlike too many psychiatrists who just hand you some pills and tell you to keep a journal or something, Dr. Dispensapill is also a skilled psychotherapist. And yet he tells me there is one thing he cannot fix: a broken heart. But we talk at great length about grieving.

For those of you who have lost a parent due to old age and infirmity, it can be a powerful event to witness. You grow up thinking your parents are immortal, and yet one day, there they lay in front of you, knocking on the door of the world to come. I had always seen my father as a physically, intellectually, and emotionally powerful man. And to see him as I did that day… There is a lesson to be learned there, but to be honest, the wounds are still fresh, and I have not yet had time to truly understand them.

February 13th, 2021 – 6:00 AM

My phone rings. The caller ID says that it’s my mother. My heart freezes. There is only one reason she would be calling me this early. I answer. She says; “It’s over for us. He’s gone.”

It’s been a tough few days, but I’m managing. The outpouring of support from friends and family has been a huge help. But I feel numb. Dr. Dispensapill said that this is normal, to feel numb for a while. Then, as my mind begins to process the loss, emotions will come out here and there, in many forms. If I feel anything these days, it’s a little bit of stunned, a little bit of sadness, and a whole lot of fatigue. It’s been an exhausting experience.

But, in a way, I also feel a sense of relief. I am relieved that my father is finally at peace, and I am relieved that my family no longer has to watch him decay further into such a poor physical state.

Please allow me to return to Kübler-Ross’s stage’s of grieving. Like I said, I am still numb, and emotions are slowly coming out, but much of what I feel applies to her five stages of grief: denial, anger, bargaining, depression, and acceptance.

1) Denial: I really don’t feel this. I know that he is gone. What helps me in this regard is knowing that his health had been deteriorating, his body withering away, for some time. There was no sense in denying it.

2) Anger: I feel none. I am very fortunate in this regard. Many times, when someone loses a parent, there be anger or bouts of acting out, particularly if the child feels that there were unresolved issues, or if the child harbored resentment over the deceased parent’s actions of some sort. My father and I had a fantastic relationship.

3) Bargaining: I must admit, I feel a bit of this. What if they had given him a little longer before they began the morphine death process? What if he had come out this decayed state? What if some physician had tried something new or novel? But I cannot hold these thoughts as rational. It was quite clear that my father was ready to go.

4) Depression: Yup. You bet. It’s not a clinical depression, like I’ve struggled with in the past, however. It is more of an emptiness. I still feel numb, yet the depression will manifest in different ways. I’ve been extremely exhausted ever since he died. It takes great effort to get things done, even trivial things like washing the dishes. I wanted to get this post written the day he died. It’s obviously taken longer.

5) Acceptance: Definitely. My father has been ready to go for quite some time. I could see it coming. I have expected it for a while now. It’s not acceptance in an “I’m okay, things will be alright, let’s move on and have fun” kind of acceptance. It is reality, and it’s what I got.

So I mainly go back and forth between depression and acceptance. But the truth is, everyone grieves differently. There is no perfect handbook that deals with the feelings of dying and death in an arithmetic style. Many things are never quite that simple.

I have a long process of grieving ahead of me. But I know that my father would want me to continue on, to keep learning, to keep trying to help others.

I must finish with one final, interesting thought. My background is in healthcare. I believe in science. I am an empiricist. I can’t quite pull the trigger on atheism, so I consider myself an agnostic. However, that does not mean I don’t have an open mind. There are many things about the world we live in that we don’t quite understand. Call it the supernatural, call it the paranormal, whatever you like. Maybe science will someday be able to measure these things, these phenomena. Or maybe they will forever remain our of our feeble human understanding of the universe. The morning my father died, I texted my oldest brother with the news. As he was replying, the power in his house went out. Later that day, my other older brother and I, who I share an apartment with, were discussing the logistics of who we needed to contact. As I moved through our living room, I knocked an old cane of the its mounting on the wall, close to our kitchen. This wooden can was hand-crafted by my great-grandfather in 1898. I watched in horror as it clashed to the ground. Yet it did not break. My brother and I agreed we should find a better place to display it. And of course, the day my father died, Seattle was covered in a beautiful blanket of pure white snow. There were no cars, and the neighborhood dogs were frolicking in the snowbound street. My father loved dogs. It seems then, that day, he was having fun discovering his newfound gifts, granted to him in the world to come.

I’ll miss you, Dad. I will love you always.

To my father: Richard King Schall

3/05/1928 – 2/13/2021

SEATTLE WILL KILL YOU

This used to be peaceful town. I’m a native; there’s not many of us left. I’ve seen this small town turn into a small big town, a place where rage, anger, and death lurk around every corner. The character, the small-town charm, is long gone. Seattle is not the city I grew up in. Seattle will kill you dead.

I remember when my beloved hometown was just a blip on the map. Then, around the early 90’s, it all exploded. Microsoft. Amazon. Starbucks. The Reign Man and The Glove. And grunge. What could have been a fantastic legacy has left Seattle a smoldering wreck. And it will kill you. Kill you dead.

I’m not really talking about crime, although that’s gotten pretty bad. We have an all but useless police department that’s basically given up. People, whatever their cause, can take over entire neighborhoods. We have a serious drug problem, tent cities on every block, and the dangerously mentally ill walking the street. And a city government, a bunch of ineffective freeloaders, that’s more concerned with bike lanes that fixing our problems.

But, somehow, we’re still a bunch of smug bastards. New York City? Yeah… that rings a bell. We love our little war-zone. Don’t get me wrong; there are plenty of things about Seattle that are fantastic. But that’s not what I’m writing about today. I’m writing about the Seattle that will kill you..

Oh, there’s the obvious ways, that’s for sure. This city is a short drive from 5 active volcanoes, any one of which could wake up and commit mass murder, particularly that ticking time-bomb known as Mt. Rainier. It’s a beautiful mountain now, but someday it might pull out the big guns. And earthquakes? Yeah, we got those. Seismologists have been saying we are due for the big one any time now. And then… we are dead.

But honestly, that’s not what I’m writing about, either. My focus in life is on healthcare. And there are a disproportionate amount of diseases and conditions in Seattle that will kill you.

There are the mental health issues, that’s for sure. We just don’t get a lot of sunlight. Cold air comes in form the Pacific, barely makes it over the Olympic Mountains, and is trapped by the towering Cascade Mountains, creating a sort of settled fog of gray and mist. As a result, Seattle only gets about 152 days of sunlight per year. A lack of sunlight can exacerbate mental health issues. Seattle has the 14th highest rate of depression in the United States (https://www.cbsnews.com/pictures/depression-nation-16-saddest-states/3/) Seattle also has one of the highest rates of Seasonal Affective Disorder. But, believe it or not, Seattle does not even crack the top 15 rates of suicide (https://www.businessinsider.com/most-suicidal-us-cities-2011-7#15-tulsa-okla-1). I can attribute this to Seattle’s incredible system of healthcare, led by the University of Washington. There’s a saying out west; if you have to get sick, at least get sick in Seattle.

But, Seattle will still kill you.

There are 3 very dangerous diseases that occur in Seattle at a disproportionate rate, a much higher rate, than the rest of the United States. (https://www.seattlemag.com/article/washington-hotbed-three-dangerous-diseases) It has long been a mystery as to why these diseases strike Seattle more than any other city, but theories are emerging. Let me address all 3:

1: Skin Cancer. This one is fairly obvious. Seattleites don’t wear sunscreen, because we don’t know what that is. On a rare sunny, hot day, everyone in the city is outdoors, soaking up the rare, pure sunlight. But, even on the days when it is slightly overcast, the ultraviolet rays of the sun can still strike exposed skin. There is also the concept of genealogy. Many long term residents of Seattle are of Nordic heritage. A study was made in 1991 (https://pubmed.ncbi.nlm.nih.gov/1985867/ that showed higher rates of skin cancer among the Nordic peoples of Europe. As a result, skin cancer is very prevalent in Seattle.

2: Tuberculosis. This is a relatively rare, but extremely dangerous disease. Left untreated, the mortality rate is as high as 50%. It is caused by a bacteria that attacks primarily the lungs, and other parts of the body as well. The rate of this disease has been dropping in the United States for the last 18 years, but it continues to climb in Seattle. This one remains a bit of a mystery. However, it is thought that because Seattle is a diverse, progressive city, welcoming immigrants from all over the world, the disease may be sneaking in that way, from parts of the world where TB is more common. But that is just a theory, and a rather provocative one. Many cities across America welcome immigrants, yet their rate of tuberculosis remains low. We’ll have to get back to you on this one.

3: Multiple Sclerosis. This can be a devastating disease. It is not well understood, but it is believed to be a type of auto-immune disorder that attacks the structures that protects nerve cells. There is no known cure, but treatment can alleviate the symptoms of those afflicted. Be that as it may, the life expectancy of those with MS is shortened by about 10 years. About 1 million Americans have this condition; 12,000 of them live in Seattle. The National Multiple Sclerosis Society has said that MS is more prevalent in Seattle than almost anywhere else on Earth. This has long puzzled epidemiologists. However, recent studies by the Mayo Clinic (https://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/expert-answers/vitamin-d-and-ms/faq-20058258) have shown that there may be a link between MS and a lack of vitamin D. Vitamin D comes from sunlight; I have already established that Seattle does not get a lot of sun. However, this doesn’t fit when you consider cities like Anchorage, Stockholm, or a host of Russian cities. Recent studies have also tried to link MS to Nordic heritage, with limited success.

Hey, just for morbid laughs, let’s not forget that Seattle was ground zero for the Covid outbreak in the United States. And murder hornets. The fun never ends!

So there you have it. Seattle is home to the highest rates of 3 of the most deadly and debilitating diseases in the United States. But please, feel free to visit our wonderful city anytime. Just remember: Seattle will kill you.

FROM HELL’S HEART I STAB AT THEE

I work in healthcare. I am a Certified Medical Assistant. Children hate me. They can’t see my big, goofy smile through my surgical mask. That matters little. They know who I am. I am the man who keeps Mr. Pain in his pocket.

Millions and millions of Americans hate going to see the Doctor. There are a lot of valid reasons for this. One is primarily economic. American healthcare can be extremely expensive. We are the only industrialized nation that has not figured this out, and there is plenty of debate concerning this; however, that argument is for another time. Millions of Americans also hate going to see the Doctor because they refuse to believe they are sick or in need of treatment. That’s all well and good, you hardy lumberjack, you; but many diseases and illnesses have no symptoms, until the affliction decides to kill you. Millions of Americans hate going to the Doctor because they think that all Doctors are quacks, and are just going to take your money. Well, sorry you feel that way, but I’ll probably be the one taking your vitals when the cancer kicks in that could have been avoided had you seen the Doctor sooner to prevent your illness. Millions of Americans hate going to see the Doctor because they believe Western medicine is impure and inherently harmful. There is nothing wrong with yoga, meditation, or tai chi; in fact, Western medicine has embraced these practices. To a degree; I’m really not sure that chamomile tea and ginger root paste is going to cure your diabetes. Just sayin’. But I posit this: Millions of Americans are afraid to go to the Doctor for one simple reason: they are afraid of needles.

Trypanophobia is the fear of medical procedures, especially needles. This is distinguished from aichmophobia, the fear of sharp things. Also, this is not to be confused with iatrophobia, the fear of Doctors, the White Coat syndrome, why your blood pressure goes up in the exam room even though hypertension has never been a problem for you. But back to the fear of needles. There can be good reasons for this. With an injection or a blood draw, metal is entering your flesh, and you may see blood. On an instinctual level, that’s not supposed to happen; even though on a rational level, it may be necessary treatment for an illness. It’s really as simple as that. But please allow me to elaborate.

In 1995, Dr. J. G. Hamilton, a smart man with a no-nonsense name, published a paper on this topic: (https://pubmed.ncbi.nlm.nih.gov/7636457/). He suggested that the fear of needles has an ancient genetic basis in evolution. Our pre-history ancestors were well aware that sharp cuts or bites could very well be a death sentence. There were no antibiotics; if the wound were to become badly infected, it could kill the injured. There was no healthcare to speak of, save the shaman or medicine man who may try to perform rituals to appease the deity the tribe believed in, as the injured had angered this god, bringing the affliction upon the wounded.

Another evolutionary theory by Stefan Bracha, MD, suggests that one might faint from an injury to demonstrate that a fallen combatant is no threat, and is taken out of the violent melee over the hunting grounds of contention at hand. (https://www.sciencedirect.com/science/article/abs/pii/S0278584606000091?via%3Dihub) You know, I’m still not really sure if possums actually do that. But I digress. Possums are cool.

The truth is, however, you really don’t need to go that far back in our evolutionary history to paint a simple picture of a grown adult’s fear of needles. All of us, when we were toddlers, received several vaccines. The Centers for Disease Control and Prevention has a schedule that healthcare providers follow:

This itinerary is only to 6 years. There are several vaccinations and inoculations after that, and many into adulthood. Many of the diseases listed in this chart have been all but eradicated due to immunizations. However, healthcare deeply respects patient autonomy. There are many parents out there who, for whatever reason, distrust vaccines (anti-vaxxers is the pejorative term) and refuse to get their children vaccinated, because there is a 0.000007% chance the vaccine will cause their child to grow a second head. On a serious note, this philosophy is why measles and mumps have not been completely eradicated, and, sadly, it is often the children who suffer and die.

But regarding a young child getting their shots: I posit a train of thought, a somewhat obvious one, that if one follows, it is quite easy to see why many of us hate needles. You are probably familiar with psychologist Erik Erikson’s eight stages of human development. Of course, unless you are a Scientologist, there is no perfect model for human psychology. Nevertheless, Erikson’s model has been studied and reworked by various schools of human development and psychology. Marysville Universtiy has a great article on this model, as well as others: (https://online.maryville.edu/online-bachelors-degrees/human-development-and-family-studies/stages-of-human-development/). In a healthy environment, trust and autonomy will foster in the growing human in the formative years. These healthy traits are directly opposed at the Doctor’s office.

When we are infants, toddlers, we are coddled, fussed over, and, in a healthy and nurturing environment, we are loved. Our needs are met. We have no responsibilities. Or course, there is discipline and punishment when we don’t get our way, but; again, in a healthy environment, this is for our protection. But. eventually, we are taken to the Doctor. Toddlers in particular, at some level, understand these visits, as much as they are places of potential pain.

When we are administered the vaccinations above, we certainly do not have the mental capacity to understand why we are being hurt by the scary man in scrubs. We are restrained, which is terror enough. Then, a sharp blast of pain appears on the body, usually, in the case of a toddler, on the thigh. This can be quite the traumatic experience for the youngster. I was holding down the legs of a 3 year-old once, while another Medical Assistant was giving him his shot. The young man was quite vocal in his opposition to all this. He really filled the room. And I tell you, a tiny human like that can really summon precocious strength. I didn’t like it, but I really had to hold him down. Generally, the parents are off to the side, although some assist in restraining the child, and all of them usually say things like: “It’s okay sweetie. You’re doing fine.” In the child’s head, nothing is okay, and nothing is fine. These are our formative years. We remember these events, at some level of consciousness. It is quite easy to see, then, why we carry this fear of Doctors, and specifically needles, well into adulthood.

There is a physiological process behind all of this. Most of us are familiar with the concept of fight or flight. This human (and animal) phenomenon is older than the theories of ancient man outlined above. It is ingrained into the very survival instinct off all human beings. It has been with us since we first banged the rocks together, and it continues today, when we go to the Doctor to get poked with a needle.

You have a nervous system, commanded by your brain. The nervous system carries out commands to different parts of your body to tell them what to go do with themselves. The main nervous system, the central nervous system, is divided into several sub-systems. The parasympathetic nervous system is responsible for resting the body when you are relaxed, resting, or feeding. The sympathetic nervous system, on the other hand, ramps your body up when danger is perceived, kicking in the fight or flight reflex. Our ancient ancestors had to do things like run from bears (this would the ‘flight’ portion of fight or flight). When this system kicks in, blood and oxygen and sent to the lungs, and the body is filled with adrenalin, to prepare ourselves to get the hell out of there. This reflex is with us today, although it can be associated with actual, physical danger (car crash, mean dog, airplane turbulence) or societal danger (the boss wants to see you, the principal called, collections just sent you a letter). When this happens, and one is expected to hold still, sitting in the phlebotomist’s chair, blood and oxygen leave the brain, our thinking becomes clouded, and many people either have an intense reaction of fear, or, even the big tough guys, experience vasovagal syncope, a fancy term for passing out. I’ve seen it happen.

But you know, the bottom line is this: it could be a lot worse. Depending on the skill of the healthcare provider, and the type of injection, getting a shot in the shoulder or getting a needle in the arm for a blood draw is pretty low on the pain scale. Needles today are designed to cause as little pain and discomfort as possible.

This is a fantastic article: (https://medicine.uq.edu.au/blog/2018/12/history-syringes-and-needles) The first needles were used in the second century, CE, with disastrous results, and by that I mean fatal. It wasn’t until the mid-19th century that modern needles began to take shape. But I don’t imagine those needles were all that easy to take, let alone sanitary.

Let me wrap it up this way: Have you ever been stung by a bee? That hurts! That’s because it’s designed to hurt. All of us have jabbed one our fingers with a staple before. That hurts! Those are things that are piercing our flesh. Modern needle design, with the hypodermic wielded by a skilled healthcare practitioner, really: Does. Not. Hurt. Sure, it stings a little, but it’s over in a few seconds, your arm may be a little sore afterwards, but trust me, you are probably going to be okay. When I am practicing in a clinic, I am forbidden from giving any kind of assurances, but here on this blog, I’m pretty sure you’re going to survive your shot.

Most of the injections I give are either in the shoulder, the thigh, or, rarely, the back of the upper arm. I occasionally give small injections on the inside of your forearm. Once in a while, the buttocks. I know what I’m doing. There are tips are tricks that I paid a lot of tuition money to learn. I’ll make it east on you. But, not to scare you, there is the occasional injection, rarely given, that are handled by Registered Nurses or Doctors: intraosseous, into the bone. Intrathecal: into the spine. Intracerebral: into the brain. These all sound fun, right? But these are rare, and are administered carefully and with anesthesia by a highly skilled practitioner. There is also, of course, an amniocentesis, which expectant mothers may be familiar with. But there is also cardiocentesis, when a needle punctures the heart. These are just a bit above my paygrade.

So the bottom line is: it’s perfectly okay to be afraid of needles, but it really doesn’t hurt too bad. On the second day of my externship, I have to give a vaccine to a 7 year-old child. She was frightened, scared, and crying. I did not patronize her; I told her it would hurt a tiny bit for just a few seconds, that it was okay to be scared, it was okay to cry, and it would be over quickly. She relaxed a bit. As soon as I injected her, she immediately perked up. “Oh!” she said. “That really doesn’t hurt too bad!” I happily affirmed her, was done in a couple seconds, and withdrew the needle. My mentor said she had never seen a reaction like that from a child. So, I know that needles are scary, and that’s perfectly okay to feel that way, but just remember that 7 year-old girl.

I’ve gotten very good at assessing what kind of patient I have, very quickly. Sometimes, if someone has a healthy outlook on life, but, I can tell, is afraid of injections, I usually try to lighten the mood with a few jokes:

“Well, let’s give this a shot.” “It’s okay not to look; I don’t either.” “I promise you, this won’t hurt me a bit.” “Present: arms!” “Oh… no wonder… that’s the wrong end of the needle…” I’ve got pages of these!

There is one final note to end on, something I neglected to mention. The Dentist. The Dentist uses needles, too. Your gums are much thicker than skin, so the Dentist uses a larger needle. The nonvaccine is very thick, so the needle must remain in gum for a longer time. The Dentist enjoys this. The Dentist is evil. The Dentist enjoys hurting you. The next time you go to the Dentist, bring your holy water, and banish the Dentist back to which they came. I kid! I’ve had some great dentists.

Remember: it doesn’t hurt that bad. Be like that 7 year-old girl! I’ll see you at the clinic!

Peacock Surgery

DISCLAIMER: I HAD NOTHING TO DO, AT ALL, WITH THE FOLLOWING STORY. I AM LICENSED TO PRACTICE ON HUMAN BEINGS. THIS STORY AND PICTURES WERE RELATED TO ME BY… A FRIEND OF MINE. AGAIN, I DID NOT DO THIS.

Peafowl are common birds of the phasianidae family, related to the pheasant. They are found in warm, tropical regions of the world. The male of the species, the peacock, is known for its resplendent display of tail feathers, the peacock train. They are some of the most beautiful birds on Earth.

My friend, who told this story to me, has a friend who owns a no-kill farm out in the country. The place is fantastic; friendly goats, peafowl, war-like geese, chickens, and even the last remnant of the dinosaur, the emu.

Though they may be vastly different than human beings, the peafowl can succumb to very similar ailments and conditions. This story, related to me and not done by me, is the story of a peacock with a very bad cyst.

My friend’s farmer friend had purchased a peacock. At first, he paid no mind to the cyst on the side of the animal’s face. But the cyst grew quite large, and was causing the poor bird problems with its vision and breathing. As you can see, its left eye was nearly useless, as the pressure of the cyst was pushing it out of its socket. It also had a rasp to its breathing, as the cyst was putting pressure on throat. This animal needed help.

My friend, who told this story to me, is quite familiar with cysts. However, he is not a veterinarian. Be that as it may, this appeared to be a sebaceous cyst, a very common growth. They are non-cancerous, and generally filled with semi-liquid or dead tissue. They are formed when the sebaceous gland, which produces sebum to coat skin and hair (or feathers) becomes damaged or blocked. They are typically not a problem, unless they are in a troublesome part of the body, such as this poor bird. Cysts grow slowly, and this beautiful animal would have continued to suffer.

Well, my friend, who is not me, has removed cysts before. It’s really quite simple. A shot of lidocaine, an incision, and then you scoop the gunk out. A course of antibiotics is then in order.

But, my friend had no lidocaine. This would have to be done Viet Nam style. He did, however, have two brilliant surgical assistants who were invaluable in this surgical procedure.

So, in my friend went. My friend did not know this, but a scalpel designed to cut human flesh barely works on a peacock. It took a little slicing. My friend was concerned that the animal would recoil in terror and pain, but it was quite cooperative throughout the entire procedure. More so than any human, actually, and without any lidocaine. Cysts are full of material that has no nerve endings; once you cut through the skin, you’re working with dead tissue. Also, my friend’s farmer friend told me that an animal will frequently settle down in a mixture of calmness and fear once it realizes it has no choice.

After just a few cuts, there it was: a disgusting mass of dead, crumbling, moist material. I will spare that picture. My friend scooped a lot of it out. It was… rather repulsive.

Withing minutes, the peacock’s left eye began to descend into its proper place, and the milky material in the lens all but disappeared. It’s breathing became less labored. Amazing what can happen when you release a little pressure.

Unfortunately, my friend got a little too ambitious when digging out the core of the cyst, and severed an artery. Again, my friend is no veterinarian, but he was confident that there was no major artery in that part of the animal. With some constant pressure applied with sterile gauze, the bleeding stopped.

My friend cleaned out the wound with saline, and applied some animal antibiotics. Every farmer has a bottle lying around: Tylan 200.

The bird looked much better after the surgery, but a little rough. It’s eye had returned to a normal state, and its breathing became better. My friend’s farmer friend kept up with the antibiotics, and I’m happy to say that the bird is doing just fine.

The cyst had been with the animal for quite some time, so it was unused to using its left eye. However, the little peacock brain has returned to normal use of its vision as its vision neurology has healed as well.

So, a happy ending. Again, I had nothing to do with this. It was related to me by a friend. The peacock has returned to his ostentation, and is living a happy life. This is what healthcare is all about. All life is precious.

Update: He’s looking pretty good!

Caffeine and Anxiety – Not Always the Best of Friends

 

Caffeine and Anxiety Disorders – Not always the best of friends

Well, who doesn’t like a good cup of coffee. I sure as heck do! What a great way to start the day! You have that first cup, you feel that pick-me-up, and you’re ready to go. You shake off the morning grogginess, and you feel great! At least that’s what your brain is telling you.

Caffeine is the most widely used psychoactive substance in the world. I’m from Seattle, the coffee capital of the world, (even though you can’t grow coffee beans here) and the birthplace of Starbucks. They’ve pumped the brakes a little as the world changes with the pandemic, but basically you can find a Starbucks anywhere in the world. Just turn around. But shoot, I tell you. I remember when it was just a cup of coffee. To each their own, but I do get a little annoyed when I get in line behind someone who wants a double-pump, almond, half-steamed, skim-milk, peppermint Karenchino. It’s just mud! We drink it for the caffeine!

I don’t keep it a secret, and I’m not ashamed of it, but I have an anxiety disorder. How society judges the mentally ill is for another post. My disorder has been largely held in check for a long time now, and I’m functioning very well, despite the recent loss of my father. But let’s take a look at how caffeine and anxiety work together, or, more properly put, don’t work together.

Most folks get their caffeine from coffee, a brewed drink prepared from roasted coffee beans, the seeds of berries from certain Coffea species. This makes caffeine an alkaloid, a naturally occurring organic compound, usually derived from plants. When coffee berries turn from green to bright red in color – indicating ripeness – they are picked, processed, and dried. Dried coffee seeds (referred to as “beans”) are roasted to varying degrees, depending on the desired flavor. Roasted beans are ground and then brewed with near-boiling water to produce the beverage that we all love.

I’m speaking generally of caffeine, but there are plenty of other ways to get the substance in your body: tea, soft drinks, chocolate, and, if you’re feeling like trashing yourself, No-Doz.

How caffeine works, and why it makes you feel good

Your brain does a lot of neat tricks, and it accomplishes them in clever ways. When your neurons, or brain cells, are firing, they are doing exactly that; sending jolts of electricity to one part of the body or the other, telling it what to go do with itself. To aid in this, your brain uses what are called neurotransmitters, nifty little chemicals. There are quite a few different types, and each of them plays either a few roles or many, depending on the need. There is one neurotransmitter in particular called adenosine, a natural central nervous system depressant, which keeps you mellow and composed. Caffeine blocks the actions of adenosine. So you wake up! At the same time, this blockage of adenosine results in the brain releasing other neurotransmitters, namely dopamine, which makes you feel great, and glutamate, which helps ramp up the body. But of course, the caffeine wears off after a while, your neurotransmitters try to return to normal, and you get tired. So time for more mud!

But wait, there’s more! Caffeine also inhibits the release of a neurotransmitter called GABA. GABA’s role is to calm the mind and decrease feelings of fear, stress and anxiety. So when you have a lot of caffeine in your system, GABA cannot do it’s job.

Anxiety Disorders

Anxiety disorder is an umbrella term for several conditions characterized by worry and fear. It is the most common mental illness in the United States; over 40 million people have some form of it. In these challenging times, the disorder has become more prevalent.

At the risk of WAY oversimplifying things, the physiology behind an anxiety disorder is as follows. (Yes, these is a physiologic mechanism behind it; so the next time someone tells you to just calm down and deal with life, tell them to take a good look in the mirror, worry about themselves, and don’t offer unsolicited advice. Or feel free to use stronger language, if you like.) There is a part of your brain called the amygdala. Like most parts of the brain, it plays several different roles. One of the hats that it wears is playing a primary role in fear and anxiety. Studies have shown that people with increased activity in their amygdala are at a much higher rate for depression and anxiety. In the case of an anxiety disorder, the amygdala will overreact to the illusion of fear, if you will, and signal another part of your brain called the hypothalamus. This then will activate your sympathetic nervous system, responsible for the phenomenon known as fight or flight. In doing so, this floods your body with chemicals called cortisol and adrenaline. This action increases blood pressure and pulse, increases muscle tension, and the acceleration of the breathing process. These are well-known symptoms of anxiety. In the meantime, the same mechanism floods your brain with a neurotransmitter call noreprinephine, which mobilizes the brain for action and alertness, at the cost of rational thinking. This is also a well-known symptom of anxiety.

One of the main neurotransmitters that calms the amygdala is GABA. Many psychiatric medications are used to treat anxiety, but some of the most common are a class of drugs called benzodiazepines (Klonopin, Xanax, etc.).

There are, undoubtedly, psychological factors that contribute to an anxiety disorder, but that’s for another time.

When caffeine and anxiety collide

Well then, it is clear that the physiological mechanism of action of caffeine and the physiological mechanism of action of an anxiety disorder can be disharmonious. Excessive caffeine can greatly exacerbate an anxiety disorder. Tremors, difficulty breathing, cognition problems; these can all result when an anxious mind has too much caffeine.

As an aside, I was on benzodiazepines for a time, and I thought I could drink all the coffee I wanted to. I could, for a while. But the chemical storm was raging in my head, and, as strong as benzodiazepines are, caffeine can be much stronger.

My anxiety disorder is well-managed these days, so I keep my coffee to 1 or 2 cups per day. Some individuals with an anxiety disorder find that tea or matcha works well for them, while others may use supplements. Some people with an anxiety disorder are better off avoiding caffeine in their lives altogether. I cannot diagnose, and I cannot give medical advice, but for those of us with an anxiety disorder, the role that caffeine plays in our lives must be considered.

Thanks for reading! Wear the mask, social distance, wash your hands, stay safe!

 

 

Medical Terminology (and the ancient Romans were kind of jerks)

Well, the third quarter is underway, and so far it’s going great! I’m taking 2 courses; one is Pharmacology and Medication Administration (this is what the chemical is, this is how I will inject you with it) and Administrative/Clinical review (this class is a lot of fun –  the instructor basically sets up exam rooms, and we practice on-boarding patients; the instructor, playing the MD, then gives us a procedure to carry out with the patient), which ties together everything I’ve learned so far. We are also studying medical terminology, and where it comes from. Not sure why that wasn’t covered in the first quarter; perhaps they just wanted us to get familiar with the jargon before we closely studied the etymology.

Everything in healthcare seems to have a needlessly fancy name, but there’s a good reason for that. Just about every bit of terminology a practitioner uses is either Greek or Latin in origin. There is also the occasional eponymous term, a word named after the person who discovered/invented it (Pap test, Alzheimer’s, Tommy John surgery). I’m oversimplifying the history a bit, but a long time ago, when Hippocrates and his colleagues figured out that illnesses and diseases were actually environmental and not divine punishment (although that unfortunate concept still exists today), and began to actually study the human body, the ‘English’ of the day was either Greek or Roman. Many people in the known world (which was much smaller then, than our own) spoke one of these two languages; much like a good portion of the known world speaks English today. This way, a physician in Rome could correspond with a physician in Roman occupied England, who perhaps spoke a local dialect, and they would know what they were talking about. The practice continues today.

The word ‘doctor’ comes from the Latin ‘docere,’ which means: to teach. It also shares its roots with the word ‘docile.’ The thinking here is that one cannot properly learn and absorb information if one’s mind is not calm and focused on the matter at hand.

But, as it turns out, the ancient Romans could be a little flippant. The word ‘hyster’ comes from the Latin ‘hystera,’ the word they used for uterus (think: hysterectomy). The Romans believed that women got moody and emotional because of their menstrual cycle; therefore, the word ”hystera’ shares a root with the word ‘hysteria.’ Well, that’s charming. Sure, some women do occasionally get a bit out of sorts on their menstrual cycle, but that is not a character flaw or an indication of a psychological or psychiatric disorder. A woman’s endocrine system is simply in overdrive, if you will, forcing an ovum into the uterus. So there you have it. The etymology of medical terminology is fascinating, but glib, dismissive opinions are nothing new.

Wash your hands!

3rd qtr so far