Hey nice job on blowing the election. Look what a mess you’ve gotten us into. Hillary Clinton. Wow. “Her turn” was “your turn”, wasn’t it. Buy hey, the disaster is that both political parties have collapsed, right? Right.
In Kentucky you can google Cassius Marcellus Clay, an abolitionist from down by Lexington, and friend of Lincoln’s, who said you need to change political parties every so often because they usually lose their way. So as a life-long republican, while still figuring government can create huge problems and tends to, I am abandoning these cats and wondering what you all have got. And, at no expense to you, I would like to offer some ideas on how to get decency, your long suit, back into American Leadership. Most of us grew up with moms and dads who would tell you, “you’re a democrat”. They all were.

Learning From Their Successes

It would help if you got a few messages. First of all, consider what I call “The Country Music Rule”: Country music will always be popular because most people are real simple, and they like simple melodies and lyrics they can sing the wrong words to. Though your heart may be in the right place, the road to hell is paved with good intentions. With minimal effort, you can go right over a majority of the people’s heads, the ones currently painting the map so red. And when you go so far out of your way to stand up for every little idiosyncrasy of your “challenged” compatriots, you lose people on the “ignorant right”. It’s a tree you’ll have to find a way to climb down out of.
Trumpers, for the most part, are people who look effectively after their own and expect others to. That’s a pretty simple concept, the kind they like. Many think 25 million Mexicans was enough. Why do you want them to forgive muslims who brought them 9/11 and forever removed freedom from their lives. Climate change? All they see is weather. The rest is just… over their heads.
So you might want to keep things simple, and for now as much as possible cool it on blind support for all the freaks of society. Support them of course, as quietly as possible.

The Barak Obama Effect

The Trumpers out here in Trumpville did not get much from Obama, who carefully stood for nothing and stood up for nobody in his efforts to slide a cool middle. But something he said early on about “finally being proud to be an American”, they took it to mean he “hates America”. They never got over it, and Hillary offered nothing inspirational to them, but a massively tacit sense of a glass ceiling. So you might just want to rally ’round the flag boys. Not sure how, but add it somehow to the schtick.
This should not be difficult.

“Issues of Public Health”

Several “hot button” issues could be exploited properly to bring both relief to people of challenge and oppression and replenish your reputation as being for the common man. Rather than making a bunch of laws which have made so many of your party’s foes so angry, do the pragmatic and efficient thing, which is to use existing institutions like The Centers for Disease Control and Prevention, The US Preventive Services Task Force (USPSTF), and churches and charitable organizations, and that very stout medical system we’ve built, to deliver education and advice and treatment for these issues, rather than involve government. This gets you off the hook for wanting to push new laws on a public that needs and wants less of them. So for gun laws, just don’t. Explore how you can reduce deaths from a public health standpoint. LGBT issues and women’s heath concerns, people all know where you stand on them, so don’t mention laws and threats. The decent people still outnumber the dogs out there. Just shut up about it, and stick your tongue in your cheek and say, “It’s a public Health issue.”

Think Bernie, Think Millennials

Your future is the face of the millennials. Our parents generation, that “World War Two” generation, they were sexist, bigoted, racist, and largely uneducated. Their parents generation was even worse. The Baby Boom was better, but the millennials are the most progressive yet, and they will naturally gravitate to your party. These issues matter to them. The environment, Diversity. Debt. The influence of Big Money, and Wall Street. Bernie spoke gospel, so I’d look to him as your standard bearer. There is magic is doing what millennials want you to do, and the Republicans have nothing to offer them.

End the War on Drugs

You need a “revolutionary” concept to establish your place as an improver of actual lives, and this is America’s dirty little secret. Big Red sez the world is way ready. Abundant footage exists for the indictment of this ghastly prohibition as the subsidiary of the military industrial complex it is. Criminalizing the pursuit of happiness has been, of course, a great crime perpetrated on the people of this country, and has been unevenly prosecuted on people of color and lower socio-economic status, worsening their troubles, which have come back to haunt us in so many ways.

Befriend LEAP (Once: Law Enforcement Against Prohibition; Now: Law Enforcement Action Partnership), the voice of reason on the matter, composed of former drug war warriors who have turned against the effort. It is they who were instrumental in the marijuana reform laws in Colorado and elsewhere, and I have included their ten commandments (“LEAP’s Statement of Principles”) on the site here. But you cannot count the social ills resulting from these 47 years of prohibition. The sturdy underworld. The ruination of black enclaves through mass incarceration. The revolving door between prison and the inner cities mingling those two cultures. The hearts broken and lives shattered. The out of control police force. Destruction of Mexico and so many other Central and South American neighbors. And not to mention the assault on the constitution. I know trial lawyers are a strong lobby for you and want the prohibition to continue but you must castigate them. They’re “old party”.

Got a Gimmick for You

You need a gimmick. How about getting a rich sponsor to buy several thousand books about the constitution, like Linda Monk’s book which I read three times: “The Words We Live By: Your Annotated Guide to The Constitution”. And send it out to a bunch of households, telling people these Trump folks are assaulting their lifeblood as a country (which they are), and say you just want to make sure people know the document, where every word in it came from, and that our hope here is that government of the people, by the people, shall not perish from the earth, or something like that. (Full disclosure, I do not know Linda Monk.)

Your attention span is short, and these are but a few ideas. But I have a slogan for you: In a few years you’ll be saying, “Lock HIM up, and Let’s Make America Great Again!”

Hey thanks. Hope you enjoy the site.

Part 2

Take one of those small 8 oz. things of the blue cheese crumbles and pout it into a bowl. Add enough milk such that some of the crumbles are still sticking up out of it like a deserted isle somewhere. Then add Mayo (Hellmann’s is the only mayo), and I can’t say for sure how much, but maybe three or four heaping forkfuls, then about half again that amount of sour cream, plop that in there. Then grind fresh pepper generously, probably half a teaspoon, but more than that would be OK. Then the critical ingredient, garlic salt. I use the Lawry’s, in the jar with the green lid, probably a teaspoon. More is better, but you can add too much, so be careful. Mix it up good, and it should be creamy but not too thick. If it’s too thin, the milk will fall through the salad and leave he blue cheese crumbles on the top. I’ve done this many times. Easy on the milk!

It saves OK, and for a few weeks and more. But the blue cheese gets bluer and bluer, and the dressing gets tangy. So for re-use, I usually spoon some out, add just a little milk and a good dose of mayo to thicken, and this dilutes the dressing back more like the beginning. A healthy sprinkle of garlic salt also brings back the original flavor.

Blue cheese dressing is an acquired taste, and in fact this happened to me. One day when we were around 19 or 20 my brother somehow got me to eat some blue cheese on a cracker, and I think I was half awake or something, but I ate it and it grossed me out bad, and it was several years later I finally got over it and ate the dressing on a salad and I was hooked.

What is most clear is that narcotics are a special poison to the human mind. Masquerading as pain relievers, they actually and simply serve as euphoria agents, in which state pain doesn’t register any longer. In the setting of acute injury or painful illness, there’s nothing like them, and for this we need them. But the problem is that some real “can do” and enjoyable thoughts result from their use as well, because these drugs are “turning on” the areas of the brain where we experience pleasure and feel the general goodness of life. So, people want to take them to get this feeling, which is entirely understandable. With this effect, it turns its users into “the people they want to be”, this narcotic feel-good-about-everything state. That’s what long-term use is all about, and it has nothing to do with pain. For the sadness in the heart of people with chronic pain syndromes, they serve to mitigate the misery or their existence through the artificial inducement of euphoria.

The bad news is this. After a time of regular use this effect fades, and we say the brain has adjusted and is now “tolerating” the drug, blunting the effect. And if the supply is interrupted, within hours a “readjustment” will begin, and in fact, by definition, addiction is defined by the existence of this withdrawal syndrome that follows stopping a substance. It is this withdrawal syndrome that is so awful and keeps people from going clean from narcotics. And they will do just about anything to not hurt like that and feel like that, for three days non-stop. The abdominal pain and diarrhea, and how every bone in your body hurts. And the headaches, oh the headaches. No sleep, no break from it. For three days, just you and your misery. And that cold-turkey looking back from the mirror. People say when it’s over they feel dead, like there’s nothing left of them.

It’s hard to say how long it takes before such “tolerance” develops, where you’re only treading water, and taking the opiates in any form to keep from withdrawing. I’d say if you’ve been taking one several times a day, like they’re prescribed for things like broken legs, for a period of weeks and not months, you’re probably getting there. And if you’ve been at it for two or three months, that’s probably gotten you there for sure. When you try to quit, we’ll know.

More bad news. Once a person has been to the point of addiction there is no going back to the old you. It’s like a head injury sort of, where you recover but there’s a something missing or different. And you’re a fight with your boss or a death in the family from falling back off this wagon, even after years of sobriety from them. So the problem is a gift that keeps on giving. We will be living this for many years. It’s why we already have been living this for years.

We all say it started with “the pain scale”. Around the year 2000, there was a survey or a study of some kind and the impression was that doctors don’t seem to address pain “enough”, and that people have suffered unnecessarily. So they introduced this pain scale, as no less than the “5^th vital sign”, where in medical interactions, after the blood pressure, heart rate, breathing rate, and temperature were taken, the nurse or assistant would ask, on a scale of 1-10, how would you rate your pain? Ten is the worst pain you’ve ever had, and 1 is the mildest.This led to a flood of narcotics into modern medicine, most notably the slow release form of the big doper, oxycodone, as “Oxycontin” (“OC’s”). Casual prescribing of these medications was enabled if not encouraged, and soon they were everywhere. For many a bad decision maker, is was the beginning of the end of their life. Literally.

Everyone in Kentucky likes to go to Florida. In the 2000’s they were going there in buses down I-75, shopping at the “pill mills”, and bringing their loot back to what eventually became a whole lot of mouths to feed them to. The mills sprung up here, too, under deceptive names, with many Rx’s signed by foreign names. A scattering of more “legit” practitioners helped fuel the monster as well, just trying to help people feel better.

Soon people were taking them to start their day. Pop one of these and I’m cleaning the house and mowing the grass, and I’m the soccer mom I want to be. Then once tolerance develops and you need more and more, and more often, and God-forbid there’s an interruption of the supply (doctor’s out of town, lost the medicine or someone stole it, etc.), the withdrawal syndrome starts. All hell soon is breaking loose. So guess what, they come to see me. And they will lie and fake any number of painful conditions to get a shot of something that will pull them back from the hell of the end of this ride of narcotic-driven feel-good. Ideally they’d like a prescription of some as well, you know, until my doctor gets back.

Thieving, not seen in any other drug phenomenon, is universal among narcotic addicts. If they have a criminal record, it is almost always from stealing and bad checks than anything involving the drug itself, like possession. So they can’t get a regular job, which makes everything worse. Famously, they steal from their mother and other loved ones, or swipe something to pawn it. The real thief is the narcotics, which leads to the saying that they “steal your soul”. It’s what narcotic addicts spend the rest of their life trying to find. I wonder if any of them ever do. It is all so sad.

The next step in the disaster was “House Bill 1”, passed by the state legislature in 2012. I was so glad to see it. The pill mills were closed, the heavy peddlers hounded into oblivion, and the rules for use spelled out, and the attitude of the prescribers was that the ride was over. But just like the Iraq war, you can win a quick battle but are you ready for what comes next? We weren’t. We still aren’t. They all turned to heroin. So the slide from popping the odd percocet or vicodin, on eventually to the “perc 30’s” (the basic is but 5 mg), to the graduation of crushing and snorting OC’s. And now it dries up, and you’re injecting heroin. A race to the bottom if ever there was one.

So hence the final ingredient in this catastrophe, and yes it is a catastrophe, is the 48 year-old war on drugs, America’s great prohibition experiment created by the Nixon-era “Drug Enforcement Agency Act of 1971”. Just like with alcohol prohibition in the 1920s, an underground network sprung up essentially over night, and now this many years later it has made it out to the furtherest hamlets of society. When the pain pills dried up, these bus-stop networks had the infrastructure to supply a certain long-acting opiate that would do the job, the one they called “this new heroin”. It could be sniffed even, to get enough of a high to “not hurt all day”. For just 10 bucks! What a deal! This is called being “strung out”. But for most, soon enough they were getting out the needle, just like the bum in the alleyway. This desperate state of affairs brings a little icing to the cake: hepatitis C. We’ll be staring down a huge medical bill rescuing all these livers when 80% of them progress to cirrhosis 20 or so years from now. And I mean they ALL have it. treatment is now available. But still.

I worked for a while down at The Bourbon Community Hospital in Paris, where they have a rehab unit, and patients come through the ER for a medical screening before admission there, and I would see them. I asked all of them, what happened? And they were so glad to tell their story, like a war veteran might. For most, it was a story that was a very long one, ten years and more of over-amping this crucial pathway of mental health and function.

They shake out about like this. Maybe a third or more had a legitimate illness or injury, and were prescribed them over months of recovery. “My doctor kept prescribing them”. After a time it was too late. A startling number were teenagers.

Another large batch, at least half, were broken hearts (incest, abuse, severe neglect), where a pain syndrome is often the maladaptation of adulthood, as “pain prone behavior”. Headaches and backaches, bulging discs, and the absurdities like fibromyalgia, these are all mental illnesses manifest as pain syndromes, and when the narcotic alleviates this problem, then IT has become the problem.

Another cohort had simple mental illness, and the bad wirings of their nervous system fell prey to the “happiness” of narcosis. Before long they were “done”, generally by a well-meaning prescriber. Accessing the medical system is, for many such “poor” citizens, a power trip and esteem builder. Few have ever paid a bill. Toss them a narcotic, and you have added the sinker to the hook and line.

Others started abusing them in high school or shortly thereafter, where they became available from the home, or by someone who was getting them by feigning illness and then distributing them. Such “recreational” starts are unusual though. And there’s no “gateway drug” to narcotic oblivion.

And not everyone has the same weakness to them. I have said that “normal” people don’t like the narcotic effect, as if their euphoria pathway is quite alright without the overstimulation narcotics cause. But unfortunately the epidemic is a sort of “thinning of the herd”, where if your mind is not “happy” enough in its own skin and you fall victim to this, your genes may not make it to the next generation. Like a selection pressure fully created by The Modern Age in Modern America. And guess what, there are a lot more broken hearts out there than anyone wants to know, generally paying for the sins of dear old mom and pop somehow.

It seems to me there are a lot of options available for people who really see the life-threatening struggle it is, but they’re such zombies already, can they ever see the light again, or gather themselves for this great struggle to recover the self? I tell them they need to re-construct their personality, so broken by this class of medications. Like a head trauma patient learning to walk again. Get work, pick up a hobby, learn a musical instrument, go to church, get in shape, and take that long look in the mirror, and try to find a you worth being. For many they’re looking up at the top of a hard box. Many.

As a syndrome that is seen in all socio-economic levels of the population, they all act like twin children of the same mother. Their excuses, their lies, their disastrous decisions, their thieving, it’s part of the syndrome. It takes me usually a minute or so to know if they’ve got the syndrome, and I look at them and I wonder, what would you have been like if not for this? Before we sent you to hell on a road paved with good intentions. Before the pain scale and House Bill 1 and the war on drugs, and before Modern Age America chewed you up and spit you out. Probably just a regular old salt of the earth pillar of society, and we could have used a better you. Won’t happen now.

Among the adventures for your primary care physicians is managing the complaint of abdominal pain. And while it is very different if you’re 2 or 12 or 20 or 50 or 80, the problems range from nothing to dangerous. But unlike the complaint of chest pain, dropping over dead from it is essentially never the case, so there is time to assess the situation.

The abdomen is full of organs and they all behave differently, and you may be able to zero in on what the problem might be with a few tips. Here are some thoughts on what organs act like when they are hurting:

Appendicitis. The appendix is a little worm-shaped finger-sized blind loop of intestine that hangs down off the beginning of the colon, and is famously present in the lower right abdomen, or the “right lower quadrant” (RLQ). In the condition of acute appendicitis there is an obstruction at the pore where it attaches to the colon there, with poop material, etc., and it begins to swell. Eventually it will pop (“perforate”), and this is bad because rupture of any part of the colon spills the germs that live there (as part of normal bowel “flora”) out into the abdominal cavity, and if this is allowed to fester for some days the infection in the belly cavity gets large and out of control and threatening. Yet while it seems like at least a quarter of the appendicitis cases we see are perforated, I cannot recall any cases where the person died from it, but it is possible. Hence, it is worth getting evaluated for, if the pain is down on that side of the belly.

The condition is unusual in the elderly and littler kids, but I have seen it in all ages. The peak age is young teenagers. A typical story is waking up with pain around the belly button and loss of appetite. By noon the pain seems to localize in the RLQ, and that night there is a general surgeon in your life. Appendectomy is a minor procedure taking less than an hour usually, and nowadays is done with a fiberoptic tool.

It is difficult to tell who has appendicitis by examination, and years back we had to “sell” a surgeon on the idea that he or she needed to see the patient in the emergency department, and things like abnormal labs, fever, and the exam itself are unreliable. Hence, they used to train surgeons to find that at surgery only half of patients actually had appendicitis, to make sure they were operating aggressively enough.

Even though we don’t feel good about CT scan radiation dose, if you’ve got an appendicitis story we’re breaking out the scanner. An ultrasound can sometimes be useful but is not as good. There aren’t many cases that hide from the scanner, so a normal study is pretty reassuring. Generally, with appendicitis you’re getting worse by the hour, so if things seem to be improving you can consider waiting. If you’re on to day two I’d worry less, but I’ve seen lower grade cases develop slowly like that. But remember, if there’s an infection thing like that in your belly, you should be able to push on it and find tenderness, and any time you can find something like that in the abdomen you’d better be careful. Tenderness (i.e., hurts to push on) is a key warning sign in abdominal pain complaints of any kind. And there is the term “rebound tenderness”, where shaking the belly cavity and moving things around in there will make an inflamed thing hurt. If there’s rebound, you’re getting worse.

Barbers used to do minor surgeries, and hung bloody rags outside to dry, and after this practice ended they just made those whirly red signs to mimic the rags. Their scalpels were used by surgeons of a later day. But yes, barbers used to do appendectomies.

Other conditions: Upper abdominal pain

Pain in the upper abdomen is common and there are several organs up there that can hurt for one reason or another. There is the stomach, the gall bladder, the early loops of the small bowel (the duodenum), and very importantly, the pancreas, and it can be hard to tell them apart based on the hurt, and whether it’s tender there or not to push on. They all cause nausea and vomiting, and can affect and be affected by eating. They all hurt through to the back (except the small bowel maybe). For bad enough complaints, a series of labs, an ultrasound, or even a CAT scan can tell you what’s wrong usually. And you can run up a large bill quickly for belly pain evaluations and come up with a bunch of you know what.

Do I have a stomach ulcer? The stomach is in the upper mid-abdomen region called the “mid-epigastrium”, and deep-hurt, organ-type pain in this location, often felt radiating through to the back, may signal the stomach is hurting. Ulcers develop gradually, so the complaint is typically weeks of discomfort, usually worse when the stomach is empty, like in the middle of the night, when there is nothing but acid gnawing away at the stomach lining. The pain at times becomes intolerable, and vomiting is not unusual. Food often makes things feel better, presumably by diluting the acidic juices.

The stomach manufactures acid to a very low pH (high acid is low pH), and in so doing injures the stomach itself, and also the first part of the small bowel it empties into (the duodenum). Furthermore, the reflux of its contents injures the esophagus, resulting in the zillion-dollar antacid business. And we don’t eat a lot of rough foods like we used to, so all this acid seems increasingly unnecessary. Since the advent of acid suppressors like histamine blockers (Zantac, Pepcid, Tagamet) and proton pump inhibitors (Prilosec, Nexium, Prevacid, others), we just don’t see stomach ulcers like we used to. However, with the introduction of the over-the-counter (OTC) anti-inflammatories like ibuprofen and naproxen, we still see ulcers, and these medications are now the main cause. Alcohol and especially cigarettes are famous causers for stomach ulcers as well.

Upper GI Bleeding

Another consequence of stomach or duodenal ulcer is bleeding and hemorrhage from the organ, a life-threatening situation. There are big arteries up there and when there is bleeding it is typically massive. Blood is cathartic, so before long it is coming out the bottom of you. And after traveling through the digestive system it is metabolized to black, and the term for the black, tarry, unbelievably foul-smelling “end-product” is “melena” (pronounced MELL-ena). Many times people have no idea the black stuff is blood, and may report “black diarrhea”. But it is the drop in circulating blood volume that makes people collapse or feel weak or dizzy especially on standing, and this is what brings them to the medical system. It is the low blood pressure, fast heart rates, and loss of color that leads us to suspect that the condition of “upper GI” (for gastro-intestinal) bleeding is occurring. Resuscitation with IV fluid is critical, and often more “intensive care” is needed for stabilization. If the circulatory system loses pressure it can be very hard to get it back, presenting a potentially fatal situation. And these are very frequent emergencies.

Passing “bright red blood” from below, is scary, right? Well, it is in fact less often dangerous when compared to upper GI hemorrhage and melena. Bleeding from “below” that is red is usually from the colon, which doesn’t bleed like the stomach and duodenum do.

The forceful nature of vomiting can tear esophageal tissue a little bit and scare people, especially young people, but without melena or signs of blood loss (low blood pressure, fast heart rates, poor color), these red pukes rarely add up to something serious. Reassuring people is another story however.

Early in my career, in the early 80s, fiberoptic tools were just being invented. Now, you name the area of the body, and there’s a scope for it. Besides looking at and biopsying tissue, they also can be used to stop bleeding and open obstructions. They are very helpful managing intestinal bleeding and have revolutionized care immensely. And they have allowed for the gastroenterologists of the world to live in very large homes.

The Pancreas

This digestive organ resides on the left side of the upper abdomen, but the hurt generated when there’s something wrong can be anywhere in the upper abdomen and generally toward the midline. It can even hurt on the right of the upper abdomen, the area typically reserved for the gallbladder, so it’s hard to tell. The pancreas is a vital organ, and when something’s wrong with it, it stops you in your tracks. The pain is intolerable, and there is often vomiting, and one knows this is more than your average bellyache. The most common cause of pain in the organ is injury caused by alcoholism. Occasionally medications and high fat levels in the bloodstream can injure and inflame the organs, the condition of “pancreatitis”.

The leaf-shaped pancreas coalesces into a single duct that connects with the bile duct coming down from the liver, and they form one duct that empties into the upper part of the small intestine, so stones and sludge from the gallbladder can get loose and travel down the piping and plug up the pancreas duct. The resulting backup injures the pancreas and this can be life-threatening (“gallstone pancreatitis”). And the bile backup turns you yellow.

They say there are three rules of surgery: eat when you can, sleep when you have to, and don’t ever mess with the pancreas. It is a flimsy, fragile organ and is profoundly unforgiving. Recovery can be long, with incapacitation and starvation, since eating flares it all up again. Once they start, these problems can recur.

Haunting ERs everywhere: then patient with chronic pancreatitis. They rarely deviate from the profile of 30s to 40s, former drunks and usually drug addicts, from bad childhoods, now broken down to chronically depressed chronic pain patients. They orbit into the ER every so often with “a flare-up”, and there’s usually not enough narcotics in the box to give them relief, and they’re always wide awake and hoping, usually pleading, for more. Their labs are unreliable, and yes you can see abnormalities on CT scans, but then where are you? Usually you have validated their ghastly plight, that this little organ can make you so miserable. Even when we can’t find anything wrong with it.

As with all chronic pain patients. antipsychotics with a little narcotic is usually the key to the temporary relief we hope to provide. And bet on this: these people haven’t paid any bills recently.

The Gallbladder

The liver sits in the right UPPER quadrant of the abdomen (RUQ). Beneath it, hanging on some ductwork emerging out of the bottom of the liver is the gallbladder. This small pouch of an organ a few inches long stores bile. This residue of metabolism (bile) is dumped into the small intestine where it aids in digestion of fats in the diet. It is also responsible for the color of poop. The “gall” (bile) can sludge and form stones, and these can cause intermittent pain and lead to surgical removal for relief.

The stomach itself secretes a hormone called CCK (cholecystokinin, or “make the gallbladder move”), which finds it’s way through the blood to the gallbladder and makes it contract, and this all happens when you eat. If there are stones in the gallbladder, a right upper abdominal pain may follow a meal an hour or so later. The hurt is bad but tolerable, and people put up with it for years. But a diseased, stone-filled gallbladder can get swollen, infected, rupture even, and good luck surviving all that. And this is not to mention the possibility of sending one of those stones down the duct system and injuring the pancreas.

It’s a small industry regarding the gallbladder in the management of belly pain complaints. Usually with classic symptoms and an ultrasound that shows stones, the local surgeon can remove it with a few cool tools of the modern era and you’re home tomorrow with a small scar. But what if the tests are normal? Well, they’ll often take it out anyway, and then what if the pain doesn’t go away? Is this just some sort of chronic pain? Are narcotics involved, or psychiatric behavior? Welcome to my shift.

The Colon

The colon starts in the Right Lower Quadrant, where the appendix is. It goes from there up toward the RUQ (the ascending colon), then goes across the upper abdomen behind the stomach (the transverse colon), turns downward there on the left side of the abdomen (the descending colon), makes an ess heading back toward the sacrum (the sigmoid colon), then goes straight down as the rectum (a word that means straight), and then the anal structures form the exit.

The rectum is usually empty, and when it’s not you can tell gas vs liquid vs solid, and you knew that. There is an involuntary muscle there which relaxes when any of these substances come in contact with it, and then only the voluntary external sphincter allows for fecal continence. And you knew that also.

Constipation: The job description for the colon is to remove water and “form” stool. Low food intake, dehydration, and narcotics along with other medications can result in drying and stool retention, what we call constipation. If firm stool makes it into the rectum and down to where the relaxation tissue is (a toothy looking structure called the dentate line), stool and stool liquid leak out, and this is called stool “impaction”. Often the only help is to manually disimpact the colon with the (gloved) finger. Soap suds enema, delivered with the long hose and quart of soapy water inserted a few feet up into the descending colon, is the best treatment, and nurses love you for ordering this. But constipation and impaction are awful for the sufferers, and we do well to help out. Cathartic agents (things you can drink that clean you out) like Magnesium Citrate bottles, available over the counter, are reliable relievers of constipating conditions.

The ER is famous for poop stories, and the most notorious top 100 are all from narcotic withdrawal. And without question, with narcotics being the reliable personality destroyers that they are, it makes sense that these people become “full of sh–”, which they generally are figuratively to have fooled themselves into this catastrophic addiction. When they get overmedicated or even frankly overdosed, and are rescued with the narcotic reverser naloxone, they wake up in a pile of…themselves. That is, if they wake up at all.

Diverticulitis:  The colon has 3 bands of longitudinal muscles with areas where the colon is “bare” between them, and over the years as much as 1/3 of people develop small balloon pouches we call diverticuli. And while they may never cause problems, they famously get infections in them and cause an acute abdominal pain from the condition called diverticulitis. This almost always involves the descending and sigmoid colon, and so is a left-sided abdominal pain complaint unfolding gradually over several days. It is treated with antibiotics, and is usually diagnosed by CT scan. And like appendicitis, these things can rupture (though rarely), they can obstruct the bowel, and can bleed profusely (often when they are not inflamed as in acute diverticulitis). I have been surprised in my career how common diverticular disease actually is in our society. But as opposed to appendicitis, there is no rush to go to the hospital before one ruptures. Still, if you’re hurting and tender over there, you should check into it. When a diverticulum does rupture, the surgical repair is much more than an appendectomy, often resulting in temporary colostomy.

Crohn’s disease and Ulcerative colitis: This pair of conditions involve inflammation of the bowel as the result of auto-immunity. In Crohn’s disease any part of the bowel from the esophagus to the rectum can be involved, and in Ulcerative colitis it is the colon that is under attack. In both cases there is lots of abdominal cramping and diarrhea over months, and periods of bloody diarrhea. The diagnosis is made by biopsy and the care is necessarily delivered by the specialist in the field, the “gastroenterologist”. They are treatable conditions, and may remit for years. The typical age of onset is people in their 20s and 30s.

GLUTEN Problems

Gluten refers to the starchy wheat particles in the diet, and some people can’t break them down, resulting in chronic vague abdominal discomfort, bloating and cramping, a condition called “Gluten-Sensitive Enteropathy”. Sufferers usually don’t know they have it, and can take a long time to make a connection between the stuff they’re eating and their symptoms. Hence most take a long time to get diagnosed. Some are born with the problem, others develop it in adulthood, often after serious illness. There is usually wasting and anemia and the malaise that goes with all that, as they seek medical attention and are routinely misdiagnosed until eventually a solid practitioner gets to the bottom of it. Total avoidance of gluten basically cures the problem.

GERD

Gastroesophageal reflux disease (GERD). GERD treatment is a zillion dollar industry. There is a large, well-controlled muscle (the pyloris, a word that means fire) at the end of the stomach that allows the stomach to be the reservoir we need it to be so we don’t have to eat all day long. After a meal, the pyloris will open briefly every 20 minutes or so, and the stomach (a muscle) will contract and squish a small amount of foodstuff into the small bowel, and then it closes up again. Holding back things at the esophagus end of the stomach is a relatively much smaller muscle, the lower esophageal sphincter (LES). It predictably loses the battle against the pyloris, and as a result, food, now acidified, refluxes into the esophagus. This may range from a little “heartburn” to full-blown GERD, where there is damage to the esophagus resulting in scarring and eventually narrowing. Over time, there can be enough scar buildup, often without even noticing it has gone on, that food gets hung up there requiring a trip to the ER. The gastroenterologist is called in, and a fiberoptic tool used to clear the thing. I have worked most of the Thanksgivings of my adult life, and I believe on every one of them somebody came in with “esophageal impaction”.

In the late 80s, the new class of acid stoppers mentioned earlier (proton pump inhibitors like prolosec, Nexium) came on the market and are great at turning off the acid, and while the reflux disease continues the injury is not nearly as bad, and the long-term consequences less. So with much of these symptoms, people should feel free to medicate themselves with these drugs, previously very expensive and now affordable, and safe in the long term.

Nausea, vomiting and diarrhea, and dehydration:

Microbes attack the intestine on regular occasion as we inoculate ourselves after coming in contact with other people. When it’s a virus there is sudden onset of nausea, vomiting, and lots of watery diarrhea. Among the most reliable epidemics of the calendar year are the intestinal viruses of late summer, propagated by mosquitoes. Each germ seems to have its own personality, with some causing more nausea and vomiting and some being more of a diarrhea result. Some invade and enter the bloodstream bringing fever and the “achy” feeling, referred to as “myalgias and arthralgias”, or muscle and joint aches. A common effect of this class of viruses is “inner ear dizziness”, a vertigo, room-spinning, head-movement-induced nausea condition that can take two or three weeks to clear. Sometimes the germs get into the nervous system causing the non-dangerous form of meningitis called “aseptic” (viral meningitis).

Dehydration: A lot of people who come to the hospital complain that they think they’re “dehydrated”, with no real sense of what that means. Certainly humans have an ability to run a little wet or dry, and you can usually tell by the darkness of your urine. But look at dehydration like this: there are three degrees of dehydration: 5%, 10%, and the max, 15% dehydrated. So, from hot summer days to intestinal viruses, you may dry out. For 5% dehydrated, maybe you’re a little lightheaded and dry-mouthed, and your heart runs a little. In 10% dehydrated you’re quite flat and need to be laying down mostly, along with having dry membranes, and dizziness on standing resulting from decreased blood volume. But when we test you with this amount of dehydration, your labs are fairly normal, and while a little IV fluid helps, you’re handling the situation, and eventually the stomach will settle and you can start drinking again, and wouldn’t have died. But as you get more like 15% dehydrated, the blood pressure might be in the 70s, the heart rate in the 130s or higher, and lab testing will show that the kidneys are failing, and electrolytes like potassium and sodium are rising to dangerous levels. IV fluid “resuscitation” is probably essential for survival in these situations. So, often it is the most excellent RN who manages IV access for the life-saving of it all. While I mouse click a bunch of notes and orders and other nonsense.

And lastly, the rear end: The most common of rear end problems are hemorrhoids, fissures, and infections. Hemorrhoids are hemorrhages into the skin of the anus itself, which is a tender and soft mucous membrane. They are managed acutely with lots of soapy water soaking and a variety of salves with limited benefit. They generally must run a course of 3 or 4 weeks, when the clot solidifies and resorbs to some degree. Fissures are slits in the anal muscle from trauma and are associated with a wicked spasm after bowel movements lasting an hour. The best treatment is to aggressively apply “Calmoseptine”, a relative of the zinc oxide the surfers and lifeguards use.

And then there are infections. Pain, redness and swelling or abscess formation in the outskirts of the anus are the typical and unmistakable complaints and findings. They may require a surgeon to slice and drain them open, a painful experience. In fistula formation, a tunnel has dissected from the rectum around the anal muscles and emerging a short distance away. They drain a foul smelling combo of poop juice and infection. Again, a surgeon can “work on” these things for you, and thank goodness for that.

If you change the get-up just a little it’s grey, it’s blues. It’s dungarees and caps and lots of other fancy lids, for sure. And while all “soldiers”, they almost all have higher-ups, and some a lot of “higher-ups” that they gotta be reporting to, and that gives them comfort. A control that’s needed, to contain the thing. A soldier must have that gene where they can just “go off”, and you know, kill a guy or whatever. Drop a bomb. Fire cannon. POW! Soldier man come rockin’. But the higherup has to give me the go-ahead. And an A-OK.

Fascinating mass-migrations have been commonplace on this planet, but with this species, it always looks the same: an “army” of some kind, with generals and strategies and arms and armaments, and don’t forget, soldiers. If it weren’t for the battles themselves, the foxhole guys, the dudes manning the guns, how far do you think the leadership would get during offensives? Not far. Yet, despite the inherent risks, there has never been a shortage of such “help”.

To “sign on” to the effort, there are a few bare essentials: demean the enemy so as to eliminate the problematic psychology of killing and murder, believe your cause is “just”, and then demonstrate the immense guts needed to hurt and maim your fellow man. But that’s all so easy, apparently. Just, follow the directions, and instructions, like a good soldier.

The all-time low of such behavior, the SS of Hitler’s Germany, was a club of dudes in the 1920s-30s, and then they armed themselves (the “waffen” SS). Then once assimilated into that God-forsaken fold, they took to things like war and genocide. Though they didn’t start out ostensibly to become this, they were what soldiers always are starting out: club rats. Identifying with each other, getting caught up in the whatever, fanned by the moments, and then soldiers in a war somewhere. Pow, pow. Drink, drink.

Whatever the syndrome is, there is little doubt that it involves an ability to turn on some type of “on-switch”, one that the trainers of such mad mobs know well. If you can get dudes to brave live bullets to try to blow up a pillbox a football field away, you can get them to do anything. And obviously, it ain’t the pay scale. It’s a different allure. Of being a helper, of doing tough jobs. And certainly, of joining this mob.

Consider the power in being the foot soldier in any battle. Yeah, you’re the grunt, but you’re packing a piece, often a very good one. There’s other things in your kit too, and there’s all of you together. And while there’s risk to this perverse excitement, all deference to “the boss”, the chiefs as it were, is tempered by the simple, undeniable observation that both have: where would He be without us grunts?

But the “soldier syndrome” (willingness to do the hard work as a “part” of a big something) is by no means limited to soldiers of militias. Throughout cultures this pattern is persistent. Leaders like CEOs and even coaches are in the same positions as are defense department higher-ups. They can run the company, but it’s not like the company or he could get much done without the workers. Because without them loading trucks on the docks, of “stuff” made by their cohorts, any “war” to make commerce would be lost, of course. It just so happens they live in a smaller house.

Same deal. Despite lower “pay”, and benefits packages, and with the nature of the day-to-day routine drastically different, this same paradigm is in place. A doctor might tell a nurse what to “do”, but couldn’t do this himself in most circumstances. The QB on the team, and for that matter the coaches, wouldn’t be considered very successful if not for, say, offensive linemen doing their thing out there. And while QBs are a rare find, there are an awful lot of big dudes offering their services “in the trenches” who have no hope of throwing a good spiral. But they’ll be happy to bang heads with those multimillionaires trying their level best to level your best…player. And… live in a slightly smaller house.

Policeman. Soldier syndrome or not? Follows direction, believes deeply in the cause, owns total control of situations. Can shoot if need be, sanctioned and authorized. Boss can’t do without him. Like essentially all soldiers, he can “go off” and become dangerous. And like a soldier, he expects “the man” to have his back. It’s all so simple really, and indeed this is the essential and defining feature of this syndrome, like so many “syndromes”: pretty simple really.

Not surprisingly, see the other very important survival instinct: A severe sense of self, and that what goes with it: serve and preserve the self, and in “serving” in whatever army, with the cause being just and all that, a dignification of the identity. Very natural indeed. Not real complex of behavior, but very natural.

So what’s the point?   In all walks of life, especially in business where “employees” make all efforts work, generals, like bosses and CEOs, must somehow use and utilize their services appropriately, or else everyone involved is screwed. In modern America, the plight of the soldier in these “battles”, where there are no live munitions or bombs bursting, is under assault. From the outsourcing of their “replaceable” skills, to the skinnying of their work packages, the stagnation of their pay, the assault on their values and freedoms (soldiers might want to catch a smoke in a bowling alley, say), and the clash and crashes of their cultures where impossible amounts of money are spent, awarded, and squandered, tells him again if not again that all his hard labor and commitment has somehow gone, dare we say it, unappreciated.

It is dangerous for us as a people and as a society to ignore their needs, to drain their energies. They are the ones carrying out the orders, and filling the orders, and no doubt in their own homes they’re probably giving out a lot of their own orders, and it is these dependents on their dad or mom who are our present and future. Politicians and other moneymen may feel the need and feel the nudge to operate the machine at other levels, hoping on a trickle down that eventually improves the standard of living in a foxhole of the world somewhere. Their record of achieving goodness for these worker bees and drones of our country can’t help but be spotty at times. Bet the lower rungs will feel it and give pause, so often concluding that “He” just doesn’t care about “Me”. Next thing you know there’s a million or two of them screaming for better. And if these soldiers and their mob lose faith, generals and colonels will soon begin to fear “the frag”. (“Frag”, short for fragmentation device, or hand grenade, is the term used when a soldier blows up a commanding officer with one, an expression of deep disagreement with duties given. Born in the Viet Nam era, hundreds of commanding officers were killed by their troops in this way to avoid a fatal operation to “take a hill”).

In any country, soldiers are the workers, the serfs, the help. The generals are the politicians. The frags are elections (usually, but not always). The bullets are bucks. And recessions are lost battles. In all cases, a look in the rear-view will show the warnings of a bad operation unfolding. Only rarely is the outcome so bad that revolution takes place. But if deficit spending, erosion of civil rights, empowerment of unproductivity, encroachment of Big Brotherhood, soiling of ecosystems, and re-derangement of values are simple examples, maltreatment of the soldier is always the result, and an “army” in disarray the real worry. If you don’t take care of him, guess what’s rolling into your tent next.