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Lifestyle Changes

I looked at my last blog post. It was from June 28, 2021.

I had just met my new primary care physician. Since then we had made slow changes to my health. I tried to eat better and exercise more. It has been a journey of trying to implement what I preach. The progress was slow.

Last year, to help my physical activity endeavors (and because I have a huge interest in martial arts), I decided to start training at a local Karate school. The school I attend teaches Enshin Karate a style that traces it’s roots back through Ashihara and Kyokushin. Shortly after that time I noticed my Apple Watch was notifying me about tachycardia (faster than normal heart rate) when I was at rest. At first it seemed random and I tried increasing my water intake. I noticed that lying down and elevating my legs would help to improve the heart rate so I thought this was the problem.

After a while it bothered me that these warnings continued. And I soon realized that the days I got these warnings were on days I attended Karate class. My heart rate, I concluded, was having a delayed recovery back to a normal rate. But I wasn’t quite sure what to do about it.

So I met with my primary care physician to discuss what was going on and we decided to order a holter monitor and refer me to cardiology. The holter monitor would be worn for two weeks. I hoped it would catch these episodes where my heart rate would race. I hoped that I would be able to use it to a class or two.

When I finally got it I was able to wear in to one class. We concluded the class with three 2-minute rounds of sparring. By the end of those three minute rounds I was gasping for air and totally “gassed.” When I later received the report from the heart monitor I learned that my max heart rate was at 7:28 PM when I was sparring. My max heart rate was 200 beats per minute.

I was kind of worried about that so I backed of training for a while until I could see my the cardiologist. It turned out that I saw someone who I had met and trained under when I was both a medical student and resident. The recommendation I received was to start intense lifestyle modifications and he actually encouraged me to exercise 45-60 minutes per day and to utilize high-intensity interval training (HIIT). He asked me to set a goal of 6-7 days per week of exercise. It hurt to hear that as I was happy with 2-3 days before this. But I knew he was right.

On the one hand I was glad not to need to start medications. On the other hand, it sounded so daunting. I met with the cardiologist in late August. It is now late October. From the August to the present time I have increased my exercise but I also had gaps where I was not feeling well (ill) and other days when the kids weren’t feeling well and the madness of life got in the way of my exercise time.

I have had to accept the fact that I won’t be able to perfectly follow this plan immediately. And no matter what happened yesterday, I can try again today. I don’t have to wait until the next week or the next month to try and do it right. That perspective change has been helpful.

But I also can say that I fully understand the struggle my own patients have when I ask them to push for their own lifestyle changes. It’s hard to do. Maybe we can do it together.

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Becoming The Patient: My turn on the other side of the stethoscope

A few months ago I had a virtual visit with a new primary care physician. My prior primary care physician had left the practice and I had to find a new one. I’ll admit that I was sheepish. You see, although I am a physician I will be the first to admit that there is a lot I am not doing to take care of my own health.

One major area for improvement is lifestyle — specifically my diet and exercise. As we spoke she summarized: “you know what to do; how do you we get you there?”

And so, the physician became the patient.

I speak to many patients about what they should be doing. Speaking/teaching/educating is the easy part. The challenge is that each patient needs to own their plan and execute it. One of the main strategies we employ is providing the education so that the patient is able to come up with their own plan. It’s human nature — we prefer to do the things we decide to do rather than the things we are told to do.

Unfortunately, it isn’t infrequent that I hear patients tell me that they didn’t do what they intended to do. They tell me that they know better and they just need to do it. I fully understand. From a diet perspective, carbohydrates are my weak spot. I am not saying that one shouldn’t eat carbs, but there definitely is an upper limit of what is healthy. I also know what it feels like to come home from work and wanting nothing more than to lounge on the couch and unwind. So I do understand the struggle.

There is a part of me that hopes blogging about my pursuit of better health will help me to stay focused. I’m hoping that because I am writing publicly about it I will be more motivated to keep it up. I have even considered letting my patients know that they can check out my blog to see how I am doing whether I am doing well or not as well as I hoped. Maybe this transparency will help someone else.

I guess I’ll have to just wait and see.

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In The News: Nursing Facility Evacuated Due to Staff No Shows

Did you hear about this one? Link: Staff No-Shows, Deaths Hit California Nursing Facilities

I heard about this yesterday. A nursing facility a few miles south of me was evacuated when the staff failed to show up for work. According to this news report nearly 3 dozen residents have tested positive for COVID-19. After many employees failed to show up for the second day in a row, all 83 patients had to be evacuated and sent to different facilities.

These workers were criticized by the county public health officer:

“Nationwide all of our health care workers are considered heroes, and they rightly are,” said Dr. Cameron Kaiser, the county’s public health officer. “But implicit in that heroism is that people stay at their post.”

Kaiser said it’s up to state regulators to determine if the workers are punished for abandoning patients.

https://www.nbcsandiego.com/news/california/riverside-nursing-facility-evacuated-after-staff-no-shows/2301888/

However, others defended the workers stating that their fear of going to work without adequate protective equipment was understandable. The article I linked above, however, does not mention this as the specific reason for the large number of no-shows by staff.

Another article I found had this to say:

Natalie Visnick, a spokeswoman for the American Health Care Association, a nonprofit group representing more than 14,000 nursing homes and other care facilities, said the Riverside issue “signals a larger, pressing issue.”

“Health care workers in long-term care are having to put their lives (and their family members who they return home to) on the line every day for their residents,” she said in an email. “Meanwhile, nursing homes and assisted living communities continue to desperately need the resources that will help them battle this virus, including personal protective equipment.”

https://www.pressdemocrat.com/news/10884395-181/riverside-nursing-facility-evacuated-after?sba=AAS

This second article seems to imply that fear of catching COVID-19 due to insufficient personal protective equipment (PPE) may have been what led to the large number of no-shows. Later the article quotes the director for the county’s Emergency Management Department:

Bruce Barton, director of the county’s Emergency Management Department, made an impassioned plea for volunteers to work at nursing facilities, promising those who sign up will get adequate safety equipment and malpractice coverage.

“We are in immediate need for help to care for our most vulnerable patients,” Barton said. “Please come join us.”

https://www.pressdemocrat.com/news/10884395-181/riverside-nursing-facility-evacuated-after?sba=AAS

So let’s assume that the no-shows were due to lack of PPE. Do I blame these healthcare workers for refusing to show up? I have wrestled with this question ever since learning about what happened and I don’t claim to have an answer. I don’t think there is a “good” answer.

When I started this post I thought that by writing out my thoughts I would be able to process the information and possibly come to some sort of conclusion. But as I’ve typed away I don’t feel any closer to a neat and clean position on this all.

Many have compared this pandemic to a war.

Sometimes, in war, there are no neat and clean answers.

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So You Think You Have COVID-19?

There is plenty of anxiety. And many patients have made appointments with a request to be tested. But the answers they have been getting are confusing and often frustrating as well. What should you do if you think you have COVID-19 (the disease caused by the novel coronavirus aka SARS-CoV-2)?

The first step is figuring out if you need to go to the emergency department. If you are feeling short of breath and/or having trouble breathing, this is definitely an indication (or a reason) to go to your nearest emergency department for evaluation. Having low oxygen saturation (or hypoxia) may necessitate supplemental oxygen usually being provided by a nasal cannula.

The second step is to call your primary physician and check with your county’s Department of Public Health. These two resources should help you understand the testing capabilities of your locale and unfortunately this will be a big determinant of who can get tested if they are not “sick enough” to require hospitalization.

Many of my visits have involved advising patients about the realities of our situation and lack of adequate testing. I have had to advise patients that have symptoms that they ought to stay at home and assume they have COVID-19 and self quarantine at home. The reasoning for this is that we assume many people who have COVID-19 will be in the spectrum from asymptomatic to mild/moderate disease that does not require admission to the hospital. If people who are well enough NOT to require a hospital admission, then the information obtained from testing will not change the treatment (self quarantining and treating the symptoms).

What symptoms should one look out for? That question is tricky. As we learn more about the disease we are seeing more and more symptoms that can be caused by COVID-19. For example, early on we advised patients to be on the lookout for a new cough, fever, or shortness of breath. However there have been reports of other symptoms including diarrhea, loss of taste/smell, etc. As this is changing, I would recommend the following sources:

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I’m Baaack

This week I returned to work after needed to stay off and isolated for the last week. While I didn’t come to work, I wouldn’t consider it a vacation. My days were filled with taking care of the toddler (3 year old) while my wife worked from home. In one word, it was exhausting.

As far as recovering goes, I noticed improvement almost each day in terms of the severity of my cough. I was coughing less frequently each day. I never developed a fever. I also never developed any shortness of breath or difficulty breathing.

And so, here I am, back at work.

Stay safe and healthy, everyone.

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Paid Leave

I have seen that a few companies are offering paid leave if their workers test positive for COVID19. In theory this is great. In reality, this is bogus. 

Policies are worded very specifically. Most of the statements I have seen that list paid leave are for patients that TEST positive for COVID19.

The problem is we do not have enough tests!

At my practice (a large, tertiary, University-based clinic in Southern California), we are operating under the assumption that most people who contract COVID19 will have a mild form of the disease that will not require a hospital admission. However, they will need to be off work for the duration to limit the spread and prevent a high-risk patient from contracting it and needing a hospital stay. 

So the majority of my patients who develop fever and cough (in cold/flu season) are told to stay off work and to act/behave as if they have COVID19 but they do not have a confirmed positive test to support the diagnosis. 

Are these people going to be able to claim benefits? I don’t know the answer to this. But if not, it will be a huge disincentive for people to follow recommendations and stay home when sick. 

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Banned From Work

This week has started off oddly. I am at home. I am not on vacation. I wish I were. Instead, I am at home in a sort of self-quarantine.

Last week, as I was getting ready to go to work I noticed that I was coughing. Initially I thought that I was had a tickle in my throat and that I just needed to clear it. But the cough persisted.

At our institution our outpatient faculty clinics had already instituted a strict screening policy. All visitors to the building were funneled to the main entrance. There, two people screen any person entering regardless of whether they are visitor or employee.

The questions each day were the same. Have you had a new fever? Have you had a new cough? Any shortness of breath? Any contact with known COVID19 patient? If all questions were answered with a negative, they would hand you a sticker that said “Cleared” and a face mask.

I knew that I would fail the screening. I also knew we had a shortage of tests. I would not be eligible for testing. And, the institutional policy for returning to work with new symptoms would require me to wait a minimum of 7 days.

So here I am. At home. Avoiding contact not only with patients but with my co-workers. I understand the reason for the policy. With the pandemic we must do everything we can to minimize spread of this COVID-19 disease.

Each day I have checked my temperature. Each day I have not had a fever. My cough has improved each day. And on National Doctor’s Day, while this pandemic rages, and my healthcare colleagues continue the fight, I sit and I wait.