Thursday, January 25, 2018


Recently the grocery store in my county seat underwent a reorganization and refurbishing that left me disconcerted.  I couldn’t tell where things were, some things were simply missing, and whole aisles of stuff that weren’t groceries and were not even appealing to me — like seasonal decorations — had popped up.  I asked what had happened and was told that a professional reorganizer had been contracted to “upgrade” the store to guarantee more profit.  Sort of like a person getting an “makeover” by changing clothes and makeup.  I’m willing to bet that the upgrader didn’t come from Montana, but at least he or she got rid of the Kentucky Fried Chicken knockoff that used to be in one corner and that pervaded the store with the smell of old deep frying grease.

Something parallel but less “sensory” is happening to medical centers who contract with outsiders to reform their practices for efficiency.  The outside "experts" are often able to enforce their opinions through standards for federal grants and insurance companies.  One of the favorite reforms of these Procrustean overseers is moving everything to electronics.  The Valier clinic, which is a subset of Marias Medical Center, has just announced with fanfare that they have converted to an electronic practice.

I am skeptical.  My first thought is what about the high proportion of the people around here who don’t have computers either because they can’t afford them or because they don’t know how to use them and don’t care to learn.  Arthritic fingers and tired eyes do not encourage people to get online, as I know since I have to fight both.  In other words, the thinkers who went for this idea seem to confine their service to younger, more educated people — which is a good idea for insurers who like to insure people who won’t need any payouts — or they want a clientele of computer-adepts but don’t realize that such folks are likely to be 12-year-olds on smartphones.  

Also, they may not have thought about internet infrastructure along the High Line, which is too frazzled or unbuilt to support brisk business, much less medical emergencies.  Even electricity is undependable here.

It’s not as though I haven’t any experience with this specific medical center.  A few years ago I was substitute ward clerk in the Care Center, the nursing component, at a time when the usual ward clerk was so exhausted that she was beginning to have medical problems herself.  I was used to databases, but not the level of detail and sub-categories of meds, protocols, and so on.  Evidently neither were the people who created the programs. Not even the techie really understood it.  This was crucial stuff: not just the databases of recording that hand-written files traditionally include, but entries used to print out instructions for the nurses as they went from room-to-room.  Thank goodness that they were humans with real contact and judgement, because a one-stroke error in an amount of dosage, for instance, was potentially fatal, and the screens of input data were so complex and crowded that errors were easy to make.

The data was also used by someone somewhere to make bubble paks of the meds for each patient.  This was meant to prevent dosage errors and (maybe) theft, but could not respond to changes  in the patient that meant needed changes in the bubble contents.  Of course, in an ideal world a doctor would have to authorize the changes, then the ward clerk would put them in the database, then the next bubble pak set would upgrade.  This comes from the assumption that categories and authority are necessary controls, and ignores the reality that patients and their care-givers are both processes, as are hospital wards and their info-support.  They can change pretty darn fast and in surprising, unexpected, ways.

So I asked to be left out of the automatic enrollment in “Patient Portal”.  In any case, this computer is not secure, but it is easier to hack internet transmissions.  Because my blog discusses edgy and even illegal subjects, because much of my thought is morally transgressive, I attract people who want to hack.  People think that if they “know everything” about sex and drugs, they will be able to guard their safety.  Or there is a sizeable contingent around here that thinks if they don’t know about something, it must not exist.

I was put back into the “Patient Portal” system because I went to the Valier clinic for an A1C reading and a discussion about adjusting meds.  I expected a finger-stick test and a review of alternatives.  What I got was a blood draw for the lab (which will be expensive) and only one suggestion: moving to the new drugs administered by injection.  Free samples available which means advertising for something not yet standardized nor in use for long.

So I went to trusty "Doctor Google" which I trust mostly because of the sources of info from large studies.  These are the two that were enlightening.  “Should A1C Targets Be Individualized for All People with Diabetes?”  and  “Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options.”  

Both of them had pages and pages of bibiliography.

I had noticed that recommended blood sugar readings were  usually between 5 and 7, with 8 being cause for alarm.  And I knew that I got a score of 8 on my last AiC, which is a figure summarizing the previous months, which this time had included Halloween.  I tried to keep temptation out of the house by giving out breakfast bars instead of candy, but even so, I ate too many breakfast bars and they were too much like candy bars.  I've tried to do better.

I had not known that there was active argument between the people who prescribe meds according to data-generated bell-curves based on testing of middle-aged white people, and the people who want to customize meds and recommendations based on individual responses.  Probably the most extreme example of the latter is Peter Attia   ( a doctor who uses himself for a guinea pig and discovered that a diet that will keep him in the low blood glucose range is not what will work for someone else.  Partly this argument is coming out of political demand for better data about minorities and women.

In the paper about prescribing for the elderly, I learned a new word:  sarcopenia, which means large muscle (skeletal) wasting.  When I lost weight at my original diagnosis, it all came out of those muscles so that my arm skin sags empty and crepey.  My arms and legs are thin, but my big tummy remains.  I see this in other old people all the time, but no medical person or even any online discussion of aging has even said directly, “You have sarcopenia.”  Another thing to research.  Very much like and related to “dry eye syndrome.”  It was a couple of years before someone said, “Your eye problems are ocular rosacea which is a version of dry eye syndrome.”

The main worry in this discussion of elderly prescribing is the danger of LOW blood sugar, esp. at night.  The consensus seems to be (I might not be getting this right) is that it’s better to be a little high than to risk the drastic consequences of low blood sugar.  Good studies haven't been done yet.

My A1C is supposed to be mailed to me.  It was taken Monday.  This is Thursday.  Nothing has arrived.  I guess I'd better buy one of those home monitors to go along with my daily glucose readings, which only tell the number at the time of the finger stick.

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