Tuesday, August 22, 2017

4 am wakening

She told me that if you wake between 4 and 5 am it's spiritual.  I'd always thought it was the 'early morning wakening' of depression.  I 'm in a Communist country where freedom of speech has fallen.  Everywhere the making of a police state rises. There's less truth and the judges don't condemn perjury.
"Remember that song of the sixties, Donovan, "Beatniks are out to make it rich, must be the season of the witch." She said, "It's been going around in my head."
We'd been talking about the solar eclipse. Auspicious times.  Great celestial events.  Wars and rumours of war.
I"m wrapping myself in the St. Patrick's Breast Plate prayer, "I arise today through a mighty strength, the invocation of the Trinity, Through belief in the Threeness, through the confession of the Oneness of the Creator of creation."
"I arise today Through the strength of Christ's birth with his Baptism, Through the strength of his crucifixion with his burial, Through the strength of his resurrection with His ascension, Through the strength of the descent for the judgement of doom ......"
Then I cut to the chase, fly forward to the most comforting part,
"Christ with me, Christ before, Christ behind me, Christ in me, Christ beneath me, Christ above me, Christ on my right, Christ on my left, Christ when I lie down, Christ when I sit down, Christ when I arise, Christ in the heart of Everyman who thinks of me, Christ in the mouth of everyone who speaks of me, Christ in every eye that sees me, Christ in every ear that hears me."
"I arise today Through a mighty strength, the invocation of the Trinity, Through the belief in the Threeness, Through the confession of the Oneness of the Creator of Creation."
I am calmed somewhat.  I would meditate for hours like I've done before.I'd return to that little room with my friends where weekly we'd chant together then sit in silence, hardly knowing one another but year after year month after month gathering to sit in silence.  I long for those times. Times before the later storms. I remember the lulls in the war. I remember so well the gathering of skills and forces.
Then the winds are on me again. The hurricane is everything.  I've battened down all the hatches and cling to the mast tied to the boat as it's flung about the raging seas that rise again and again and crush me alone in the darkness and rain.
"I arise today Through a mighty strength, the invocation of the Trinity, Through the belief in the threeness, Through the confession of the Oneness of the Creator of Creation."
I know it's the trusting again. I know I've opened myself a fraction and felt the vulnerability of human kind. I've asked for help. A minor thing really to any other. But I've let them near.
I dreamed of my father and my brother and my mother and my aunt. I know it's bad when they gather.  In the past it was my aunt. She died first and would come to me in my sleep where I was scared and alone and thinking of dying.  Then my mother and father died and they joined her. Sometimes they're alone or together.  When my brother died he joined them.  I awoke to the sweet memory of their presence inside me.  They comfort me.
There's nothing better than the dogs. The dogs sometimes come. I wake and my face has been licked by my former canine friend.  If it's a tough night and I wake with sweaty and afraid my dog Gilbert is there beside me, his little body nestled close to me, reminding me.
I'm not alone. We're not alone.
My dafault channel is 'self pity' and 'anger'.  I'm an egomaniac with an inferiority complex. I don't trust well. Betrayal has been by friends.  Callous in the end.  I've been misunderstood.  The communications have broken down. I've been 'beat up and battered round'. The lyrics of the Travelling Wilbury song "Handle Me With Care" come to me.  Handle me with care, I beg, I plead, I warn.
This morning I just woke from a dream where I was with family, alive again, not dying.  There was no war and the government wasn't trying to kill it's citizens. I don't know who it is in government. There's money in death.  Someone is a collector.  It's like those science fiction tales  where the aliens have made a pactwith some of the government leadership to collect the spirits of the dead so cause death to occur through disease or war.
The fentanyl epidemic is upon me.  Talking daily to men and women who don't return. I learn from a call from the coroner.
"I'm just collecting information.  We think it's an accidental overdose."
You think. I go through the motions.  Share my last memories.  I'm important for a moment.  I knew the deceased. I'm worried that I didn't do enough. There's never enough time. The government police doctors stand with guns at our back and send us out into the front lines. I'm always reminded of that Russian movie with the sniper. The new recruits are unloaded and sent to the front against tanks and machine guns. They don't have guns.
"Get weapons off the dead," the comrade capitan tells them.  Then he stands perfect and safe, back from the front, holding his gun to shoot in the back any troops that waver.
That's the committees we get today. Rows of leaders with guns and alibis.
"I hardly knew him, " i say. Always guilty. What more could I do.
My friend died, I'm thinking. I could have gone for dinner one more time if I'd known he was going to die.
I've always blamed myself.
"Get down off the cross we can use the wood."  I'm always looking over my shoulder now.  The last judge I met was insane, drunk as a skunk and loud and psychotic.  But I must trust the position. In the rule and order there can be a weak person in a position of power but the position is good. Don't fight City Hall.  Right now the Prime Minister scares me, truly scares me, like King George the Third must have been frightening. But it's an individual, not the system.  It's the externalizations, too, of all your inner fears.
What we fear outside is what we have not faced inside.  It is what someone represents. It's the monsters from the childhood fears that come back to haunt. Not the real individuals.  I am still afraid. The rationalizations don't get me out of bed. I am prone to the fetal position.  I'm afraid of being homeless, pushing shopping carts on the street, not having toilet paper, smelling, having no where safe to sleep, having lice and bed bugs.  I am afraid of theft in the night, gangs, rape, losing organs.
Then. I think of 'principalities'.  There is such failures of the authorities. A man kills my dog.  Another threatens me for a year, intermittently like a Chinese water torture. The emails come.  "I will kill you and I will kill your dog."
I have been protecting my dog for a year and more.  He's lost his eye.  The hatred I've attracted in my work, doing the right thing, believing, serving, refusing to support violence, reporting the pedophile, having the guns removed, refusing the drugs that will make the individual more dangerous.  I'm a bulwark against the sea. It bashes relentlessly.
The beurocrat always comes to mind. Her insanity. Her power and the abuse of power as she stood before me and said in that haughty whining voice, "Women don't lie about sex."
I am in a jail and I want to run away but I don't believe there is any escape and I know too well that women lie about sex. Women lie, Men lie. Humans lie.
Even today I faced a man and unravelled lie upon lie until i found his history of violent past and wondered how I'd come to this place again.  Faced with his fear and violence in a room with help so far away remembering being held hostage and threatened that night. It flooded back.
But I don't mind him. I'm scared. It's right to be scared. He's scared. But the beurocrats they really frighten me. They're so far from reality a homing pigeon couldn't find them. They have lost their centre. They're as sick as today's media.  There is surprise everywhere. Upheaval. Those who claim to known don't.  The uncertainties have never been greater. So the beaurocrats who have lived their lives in terror staying as far from reality as one dares, congregating in packs, joining with others in echo chambers , packed lemming like together in offices of distrust and deceit, reassuring themselves, mutually, seeking ever for scapegoats.  Always they sacrifice virgins and novices and let the blood out of the jugular before they eventually eat the corpses and secretly wipe their chins and smile.  Eyes glowing.
"No in all these things we are more than conquerors through him who loved us. For I am convinced that neither death nor life, neither angels nor demons, neither height nor depth, nor anything else in creation, will be able to separate us from the love of God that is in Christ Jesus our Lord."
Paul had a flowery tongue. He was a great orator.  He believed and was persecuted.  I fear persecution. I have been baptized.  I've felt the sprinkle of holy water and have been immersed in the river of Jordan. But even bathing in and swallowing copious amounts of hyssop hasn't left me purified. I'm barely sanctified. I'm not even sure at times what the words mean and too often I feel that experience of being alone before that other experience of unsurpassing joy and connectedness with divine.
I'm held in the arms of love. I'm again a babe in the lap of my mother.  Pieta.
"For by him all thing were created: things in heaven and on earth, visible and invisible, whether thrones or powers or rulers or authorities; all things were created by him and for him."
"And having disarmed the powers and authorities, he made a public spectacle of them, triumphing over them by the cross.'
Ephesians 6:12 "For our struggle is not against flesh and blood but against the rulers , against the authorities, against the powers of this dark world and against the spiritual forces of evil in the heavenly realms."
I know this.  I never feel evil in my fellow man but see the sickness. I would free them from disease. I believe in death that I am released from this corporeal form and live on in spirit, in Grace.  This is a passing phase and limited time in an eternity of timeless time.  I am only now on the surface of things.
There is victory and reassurance in these phrases of Paul but earlier in John Jesus says, "I will not speak much more with you, for the ruler of the world is coming and he has nothing in Me."
That's the rub as Hamlet would say.  The "ruler of the world".  Obviously that was then before Jesus died. Before as the old timers said, 'there victory in the blood."
I just learned that Steven King recovered from alcoholism. I too am recovered from alcoholism. I once got drunk and escaped this world in 'demon drink' and felt the illusion of peace for a time only to return to having greater anxiety.
Now I awake in the night and am comforted by my dreams but anxious to face the day.  I fear I'm not a very good Christian. I'm partial to all the character flaws that are called sins in the old language. I especially like gluttony, sloth and lust and anger and envy.  Pride is my go to place. But I know pride goeth before the fall so I'm ever on the watch for Murphy's law. I'm the Fool in the Tarot deck ready at any moment to step off the preciprice.  I strive for wisdom and peace and calm and then a moment passes and I realize I've trusted again, that I've opened myself a little. I feel the scars pulling where the previous wounds were made. I let someone touch my back today where the untouchable is and the wounds reside.
"Et tu, Brutes".  His friends gathered round him and stabbed him over and over again in the back.  I am partially healed.
John says, that "They will wage war against the Lamb, but the Lamb will triumph over them because he is Lord of Lords and King of Kings - and with him will be his called, chosen and faithful followers."
I 'm tired again. I'm going to go back to sleep for another hour of rest before the work day begins.  My dog is asleep. He will wake me as he does by licking my face and cuddling. I can look forward to that. I don't know what came over me this morning. The first dreams were so wonderful but then I thought of this world and became afraid again. Now I'm comforted. There is always comfort in the scripture. Yet I don't read it enough,. I am reminded sitting around the table at St. John's discussing the teaching of Jesus with the other men and women and how comforting this was.  We gather together to read and discuss another book too that first was written by men who together believed in this good book.
I'll go to bed again. I've self soothed. Thank you Lord.   Thank you Jesus.  Thank you Mom.

Monday, August 21, 2017

Psychopharmacology for Depression (idiot's guide to CANMAT)

The following is an off the cuff review of my clinical experience.  I have this information available for me and it forms the basis of my treatment plan before I consult CANMAT.  If I was a new doctor I might look to CANMAT earlier rather than later but I've seen and treated thousands of patients so use my clinical experience first. If something goes wrong, I, not CANMAT, will be faced with the consequences .That said CANMAT produces great tools.
Also if you have any question about particular medication I've found that the manufacturers are an amazing resource.  A lot of the internet information is not.  Much of the information is false and put forward by competing interests.  CANMAT and the actual manufacturers are the best resources.

1. Depression - there are a variety of antidepressants which fall into the following principle categories.
A. MAOI's - I've only used these a few times in the last 30 years. They were highly effective but their problem was interactions with other drugs and certain foods.This could lead to a hypertensive crisis.
B: Tricyclics - these were the mainstay of treatment when I began. The first was amitriptylline and imprimane.  We don't hear much of imipramine these days but amitriptylline is still used widely. It's specific benefit is at low dose (under 10 to 50 mg ) it's a very effective sleep medication. It's other advantage is that it's very helpful with chronic pain, chronic fatigue and fibromyalgia.  One theory is that amitriptylline improves the depth and quality of sleep and hence reduces the anxiety and pain.  These were introduced in the 1950's and one of the main reasons for the reduction in stays in asylums.  Depressions untreated could last 1-2 years and the efficacy of the tricyclics was that within 6 weeks people could be functional again without depressive symptoms.  Medications were recommended in general from 1-2 years.
Norptriptylline and Desipramine are the second generation tricyclics which still are used not uncommonly in the treatment of depression especially when the depression is diagnosed as 'atypical' or when the SSRi and SNRI's have been used and tricyclics are consdered next.
These second generation tricyclics have fewer side effects.
The principle side effect that people complained of was dry mouth.  Also low blood pressure with standing quickly.'The side effect of urinary retention has lead to tricyclics being used still in the elderly where night time urinary incontinence can be a problem.  The limitting factor was that with overdose they could cause arrhythmia and patients who overdosed had to be followed in ICU or at least on a heart monitor for a few days.
The tricycles start at 10 mg and are used up to 300 mg without compounding medications or conditions if necessary in the treatment of depression.
C: SSRI - the first SSRI was fluoxetine or Prozac.  The real advantage of the SSRi was that there were far fewer side effects, that they could be used more safely with other medications and that they had to be taken in very large amounts to cause suicide.
Prozac was introduced in the 80's.  Since then there has been ongoing studies of the children of mothers who received Prozac and they've shown very very few side effects, perhaps some increased anxiety.  That makes the SSRI class one of the safest medications in history, certainly safer than alcohol.
Fluoxetine (Prozac) was begun at 10 mg and could be increased to 60 mg. I've used 100 mg on patients with OCD.  I continue to maintain Prozac is the treatment of choice for OCD.  It was a better anti anxiety medication than tricyclics in general.  Anxiety and depression thought to be different conditions often overlapped and the antidepressant medications are commonly the mainstay in the treatment as of chronic depressions and chronic anxiety disorders.
The SSRI"s are considered the mainstay treatment of choice for  chronic Panic Attacks as well.
Second generation SSRI's included the following medications:
Sertraline or Zoloft - used 25 to 150 mg - this was a very good antidepressant but it quickly became the treatment of choice for PTSD and later for Social Anxiety.  It remains a very well tolerated and well liked SSRI.  The advantage of the secondary and later SSRI's was their shorter length of action in the system.  Prozac had a long half life (half life the metabolism of a drug, the longer the half life, the more in the system, the shorter the half life the more quickly a drug is cleared from the system).  Prozac could build in the system without us knowing and while this was beneficial in the treatment of OCD which is resistant to treatment it could lead to Serotonin Syndrome which is much worried about these days.. (I"m less anxious about Serontonin Syndrome since I've actually treated several cases when I worked in the asylum and only saw it there where we were using experimentally high dosages.)
Fluvoxamine or Luvox was another second generation SSRI. I simply didn't use a lot of this in practice but my colleague favoured it as a good antidepressant.
Paroxetine or Paxil - used at 20 to 40 mg - was an especially popular medication for depression, anxiety and anxious depressions.  The problem was that it had the highest sexual side effects of all the SSRI's.  The sexual side effects were loss of interest, elective failure, lubrication loss and lack of potency. 40% of patients in one study complained of this but only if asked.  Interestingly Ginkgo Biloba counteracted most sexual side effects. Viagra and cialis counteracted the sexual side effects of the SSRI's but not just for men but for women as well. My female patients told me they just said it was for their boyfriends (wink, wink).
Now I don't know why but Wellbutrin or Buproprion an atypical SNRI. (Works on Norepinephine and Dopamine)  , the only elevating antidepressant, worked as well to counteract the sexual side effects of Paxil.  Combining Wellbutrin with an SSRi also addressed the fatigue some people described with an SSRI
About half the people took the SSRI's in the morning in comparison with the normal evening dose of tricyclics.  However when Wellbutrin or Buproprion was used this was taken in the morning and the SSRI in the evening.
Trazadone (?Oleptro) is an SSRI that is principally used for insomnia.  It was at first an antidepressant and was very effective as an antidepressant at 300 to 600 mg dosage however patients found it to be a terrific sleep medication in the 25 to 200 mg range, most commonly at 50 mg.  It caused too much 'hang over' and sedation for most people. Today it's particularly special effect is that it can be used in combination with all other SSRI or SNRI's where insomnia is a major problem. This way it boost the antidepressant being used and addresses the sleep disturbance.
Third Generation SSRI
These are Citalopram (celexa) and Escitalopram (Cipralex). These are the latest SSRI's and have the advantage of shorter action, less side effects and amazingly safe use with other medications. Hence if I had an elderly patient with heart disease, diabetes and COPD with depression I was scared to start a tricyclics or even Prozac because of it's long action but I've been using Celexa and Cipralex extensively and safely in these complex medical cases. Citalopram or celexa is a better antidepressant than antianxiety drug, while escitalopram is a better anti anxiety drug.  Both start at 10 mg and can be increased to 30 or 40 mg. I've got one or two patients on more but it's generally not recommended.
When asked when to change a medication to another medication because the first doesn't appear to be working I like to use at least 1 1/2 times to 2x the recognized dosage of efficacy before saying a medication doesn't work.  Hence I'd use at least 30 to 40 mg of Citalopram before considering I'd had a worthwhile trial.
I start low with medication using the reccommended or half the recommennded dosage of the medication initially. I expect to see benefit in 2 to 4 weeks and would increase the medication on an outpatient basis, in the community at 4 to 6 weeks if the patient isn't getting better. However if the patient is improving I will go slower with the dosage increases definitely.
SNRI - Serotonin Norepineprhine Reuptake Inhibitors
Venlafaxine or Effexor is the first generation SNRI.  It's also been called 'broad spectrum'. It has very good antidepressant and anti anxiety benefits and I've seen it used superbly in the general practice for patients with mild to moderate depressions requiring medications.  It's problem for me personally is that as a specialist I get patients coming to me when the medication, which starts at 37.5 mg effectively is slowly increased to the maximum 225 mg range. Past 150 mg my tendency is to call this medication 'side effexor'.  Alone it is an amazing medication and it can be augmented really well but it interacts with other medications and in contrast to the SSRI's where higher dosages can be achieved, the side effects with venlafaxine increase in a hockey stick curve, anecdotally, clincally, after about 150 mg.
The STAR D Protocols which are very much written about were an amazing study of chronic depression and they compared two streams of patients with the SSRI Celexa in one and the SNRI in the other stream.  This is an essential study for anyone doing long term psychiatric treatment in the real world. The clinicians involved were the finest and the questions raised and addressed were the bread and butter of psychiatric practice.
Augmentation
The Star D protocols used a variety of augmentation strategies.
Buspirone - Buspar - this is an atypical anti anxiety agent like Valium or Ativan without the addiction potential.  In my practice about a third of patients I 've prescribed it to have sworn by it. It can be used at 10 mg a day to a maximum of 10 mg four times a day.  It was used to augment the antidepressant in the Star D protocols once one had achieved the maximum dose one was going to use, approximately 1 1/2 to 2 x the standard dose.
Thyroxine or synthroid was another augmenting agents in the STAR D protocol studies
Stimulant medications such as Ritalin or Dexedrine in low dose are also used to augment anti depressants where the patient has a history of head injuries, the medication side effect is weight gain which is not wanted,  and where the patients depression is associated with a lot of neuro cognitive symptoms like lack of concentration.
Atypical antisychotic augmentation is commoner these days as increasingly people are diagnosing Bipolar Spectrum and Bipolar II disorders which tend diagnositically overlap with the traditional Major Mood Disorder Depression or Unipolar Depression or the traditional Anxious depression.  The principal low dose atypical antipsychotics used are Seroquel, a very good sleep medication, in the range of 25 to 100 mg in combination with an anti depressant, rispiridone .25 to 1 mg of or ariprazole or ability 2 to 5 mg od.
It should be noted that the atypical anti psychotic or major tranquilizer class of medications including those named plus olanzepine are the mainstay treatment of Bipolar II and Bipolar Spectrum treatments.
The antiseizure drugs such as Valproic Acid, Divalproex, Carbamezapine or Tegretol, and Lamotrogine or Lamictal are perhaps today considered second line treatments or to be used in combination.
Diagnosing Bipolar II instead of Unipolar Major Mood Disorder makes matters a whole lot easier for the clinician because almost all of the pharmacopeia of the psychiatrist can be used in the treatment of Bipolar II.
I'm called upon to 'rationalize' and reduce the overall medications used in some exuberant prescribers.  When this occurs I try to use different classes of medication before using three or four of the same class.  Further I consider the medication choice by the presence of other symptoms and choose a medication where the side effects of the medications can be beneficial for the patient.  Recently I used a tricyclics as my first choice of medication because the patient had urinary incontinence. Normally my first choice would be an SSRI.
Duloxetine or Cymbalta is a unique SNRI.  It's an excellent antidepressant.  It's also been studied for the treatment of fibromyalgia and chronic pain. It's an amazing drug.  Commonly Amitryptylline at low dose was all we had for chronic pain conditions now called by DSM5 Somatic Sympton Disorder but duloxetine came along and has far greater benefit without the side effects.  It's started at 20 mg and increased to 120 mg with most people finding 60 mg effective.
The term 'somatic depression' was commonly in use in the past to refer to conditions such as chronic pain and lethargy and a variety of depressions where the person felt bad but didn't really 'think' bad. It wasn't like the person was saying to themselves I'm hopeless but I just feel awful instead. This was where Cymbalta was a true breakthrough.
All SSRI and SNRI's have an initial side effect of some indigestion and nausea.  There are a variety of ways to counteract this. First start at the lowest dose, take every other day at first , use ginger and lots of fluids and slowly increase.
Vortioxetine or Trintellix is the latest of the antidepressant which seems to be the latest  atypical SSRI.  It specifically antagonizes  5-HT3 receptors while agonizing 5-HT1A receptors. The outcome is that it's an extremely good antidepressant but it really works on those depressions where people have cognitive concerns such as decreased concentration and memory. It also is specifically marketed for those people who have a successful response to antidepressants in the first year but describe not feeling themselves again, that they're specifically cognitively not where they were, in terms of motivation and ability to do computer or office work. It seems to enhance thinking and my patients have found it superior in this way. This has been an antidepressant that my academic patients , professors and such have found highly effective for them.
Des venlafaxine or Pristiq is the latest atypical SNRI. It's the broadest spectrum of antidepressants and appears to be an advanced Effexor without the side effects. It has a window of benefit in the 50 to 100 mg range with not noted benefit with increase.  It's amazing for it's tolerance in general by patients, and the lack of side effects. Like Effexor it really helps with the patients who have a mixed anxiety depression picture. I've only had good feed back but have limited experience with it as it's more commonly used by those seeing first encounter cases where it 's broad spectrum benefit helps with ensuring that patient get early response.

CANMAT is the Canadian Network for Mood and Anxiety Treatments. The organization puts out guidelines for treatments and the 2016 CANMAT Guidelines are excellent.  Since my all time favourite mood disorder genius Dr. Solomon retired recently I have found myself looking at the CANMAT guidelines directly not being able to phone Dr. Solomon and ask him what to do when I've been stymied. These Guidelines are amazing if a bit more complicated than what I've indicated. They are an essential for anyone treating psychiatric patients.
Www.canmat.org







Sunday, August 20, 2017

Sunday Walk and Keystone Fuzion


My legs hurt from the 5 k run yesterday. I actually ran most of it and only walked a bit.  Gilbert had come for a poop and pee then insisted he go back and protect Laura who was still sleeping.  He's really a suck. Sitting beside her as she is lying in bed he puts his paw on her arm and she begins to pet his back or scratch his belly.  That's so much better than a run which I think is sore for his back.  If I wasn't fat and out of shape I'd crawl back in bed with Laura. I was glad for the run though.
Today Gilbert got his walk along the Brunette River. A Gilbert walk as opposed to a Bill run involves lots of sniffing and lots of peeing but not rushing about.  It takes a long time to complete a goodly Gilbert walk.
The sun is shining. It's hot. I love it.
Laura was up early this morning. Her sister and John were picking her up to go with Robin to Cultus lake to meet family and friends and see the granddaughters and grandson.  Laura's granddaughter Paris and Robin are best friends. The newest grandson, Everley is really cute.
I like when Laura sees her grandchildren. She's such a lovely lady and children and animals gravitate towards her. Just yesterday the neighbour's little 5 year old took her by the hand and said,"Lets leave the adults and you and me go for a walk."
With that she took Laura by the hand and chattering all along walked away with her.  I was left talking with Laura and Rick and Dave. There were others there whose names I've sadly forgotten.  Gilbert was so happy to see Dave's dog Emory and visit with the chocolate lab and blond lab. He likes them all.
My big event yesterday was going to Meridian, to look at the 37 foot Fuzion and talk to Steve.  We're hoping to go back next Saturday and that all goes well. I've been looking at new digs for a few weeks. It's been a plan in making for months.  I live in my Keystone Energy which I got and have used for hunting. The fact is I do more living in it and less hauling in it which Laura pointed out. So the Fuzion 5 th wheel is more space and more elegant and also a toyhauler. I doubt I'll be taking it off road anytime soon if the deal goes through.
I have to get an endorsement for my license and called Burnaby Hitch to have a toyhauler removable hitch installed in the new Ford F-350 Lariat edition. Then once I have a machine I have to get a teacher to train me in hauling it. I actually also have to take an actually driving and hauling text.  I like that the government has required this. In retrospect I would have had more peace of mind if I took lessons in towing my previous machines.
I'm really no good at backing up and have all manner of anxiety towing despite doing it and  getting by. This unit is that much longer and that much heavier but the fifth wheel arrangement distributes the weight and I'm told makes backing up easier. I'll have cameras on the new unit as well.  in addition the Fifth Wheel is least likely to shimmy in the wind going downhill/. That's been a trial coming down the Cocahalla Highway off the escarpment and  the coastal mountains.
I picked black berries on the walk today. Sweet. Took some pictures of flowers too.  This morning after Laura left with her family I eventually  had a shave and shower.  Laura's sister and brother in law are terrific. They don't look any different than they did when I met them some 15 years ago. Their daughter sure has grown.  She's a young woman going off to New Zealand for a month next week. Laura thinks the world of her.
I thought about my nephew Alan going to Coventry England for a year of work and study with his partner Meaghan who is doing a year of forensic psychology.  Robin must only be about 20 and I can't help but think how our parents must have been terrified when Baiba and I flew off to bicycle across Europe at that age.  Alan's much older and finished his psychology but I confess young people seem more vulnerable.  I'm old and scarred and dangerous.  It's been a hard learning curve but I survived it and so do the young. I hope it's much safer than it was in my day.  They'll do fine.  Cell phones alone make life less isolated.
I'm reading a Captain Steel novel.  British Grenadiers fighting the French under Marlborough in the 1800's.  Back yard summer reading. I listened to a pod cast while I walked ,of 13th century Hildegard of Bingen, one of four Doctors of Letters of the Roman Catholic Church.  I like the history podcasts. I had just listened to a medical podcast on Placebo Effect in the car.
I ate Me and Ed's pizza left overs for lunch. Laura and I had enjoyed it fresh last night. Great crust.
I've concluded I'm on call.  I've no big expedition or project in motion. I'm just muddling along.  I've a sense I'm recovering from a particularly difficult time still grieving, overworked by the need to move. Disappointed by ethical lapses of others.  Glad to be in these clinics.  I really like the other doctors and colleagues I'm working with. The Fentanyl epidemic is taking it's toll.  I enjoyed getting to Whitecliff last week. IDAA before that was so  inspirational as always.
Now it's time to get back to reading on a lawn chair in the sun. Gilbert is on his leash lying beside the Harley at the front of the property, guarding and sniffing the wind. There's a lot of dogs here right now. They come and go but this weekend has been a real doggy social weekend.
Thank you God for all your blessings.
 

Saturday, August 19, 2017

Homosexuality and Christianity

First and foremost, I tell people that Jesus did not talk about homosexuality.  I've read the Bible and as much as I look I don't see anywhere that Jesus spoke about these issues. He talked a lot about God instead. Consequently I think the failure of the present day church is that it has been brought down into the realm of social discourse.
What L'Chaim means is 'to life'.  Fundamentally Christianity is about creativity as was Judaism before.  This issue with homosexuality in Deuteronomy was that a tribe's success in the days before the Industrial Age depended on reproductive numbers. The more in a family, the more power; the more in the tribe ,the greater the number of warriors. Warriors meant you could get slaves. Slaves and peasants tended the fields.
(Note that the argument of Islamists today is that they will rule the world through the fertile wombs of their women. Much of Islam remains in a pre industrial consciousness due to the denial of fundamental freedoms for most especially women.)
The role of the Mother in the Church is sacrosanct.  When childless girls were elevated to high status in the church without being celibate nuns, the same with celibate priests, the introduction of whether one was lesbian or homosexual or heterosexual became a mute point.
Celibacy by contrast is associated with spirituality and increased enlightenment in many religions not just Christianity.
The onset of 99% effective chemical birth control in the 1950's and choice of abhorrent abortion over celebration of birth and motherhood were game changers.
Paul was an old Jewish leader who made mistakes.  Nothing Jesus says is dated but some of what Paul says had a short shelf life. Jesus was God and Man.  Paul was at best a godly man.   I can't accept the infallibility of the Bible when I read about Paul's statements regarding slaves. He was a Rabbi and may have been married but the evidence suggests not.  His comments regarding women and men and marriage aren't necessarily wrong but somehow sound dated. Nothing Jesus says sounds dated except his local and historic metaphors, mostly about fishing and farming.  It's lost on kids living in a concrete jungle of parking lots of mechanicals.
So Individualism is central to all these discontents. The destruction of the family is fundamental aetheist communism. The religion of the STATE as God as created by Marx and Engels and Lenin and Stalin an Mao is simply based on the reality that individuals can be dominated by the fundamental divide and conquer tactic of the State.  So we have the rise of Individualism out of Marx and Engels who were outspoken about the need to destroy the family.  They didn't like Mothers especially theirs and others.
Jesus by contrast simply said that God must come first even if that separates you from family. Jesus did love his mother.  Marx wanted family ties destroyed with only one relationship of importance, that of individual and Aetheist God State, (the committee).  Even the Kings and Emperors of old supported the serf's family.  Family was the fundamental unit of society not the individual.
Today all the sexuality and social issues especially around "Identity Politics' is a priori about individuals.  Jesus spoke of the individual relationship with God.  In my relationships with others in my family and community I reflect my fundamental relationship with Jesus Christ.
The tendency of Evangelicals to call the Bible, the Old and New Testament is flawed. The GOOD NEWS is the Gospels. All else is secondary.  All else is truly commentary.  Jesus summed up the scriptures with the statement Love God and Love Thy Neighbour as Thyself.  This is a key to understanding every phrase in the rest of the Bible, everything said by Paul, everything said by Isaiah. If it doesn't fundamentally agree with what Jesus says its being misinterpreted or cherry picked or selected out of context.
I personally identify as a Christian and as a member of the family of Christians.  I am first and foremost a Christian as that speaks to my most important relationship, that with my Lord Jesus Christ.  Jesus Christ is the name I use when I speak to my God.  All other relationships sexual or otherwise take a distant second. I don't hear that in Church dialogues and see the emphasis in Gay flavoured churches and Anti Gay churches as missing the point.
The point of Christianity is Jesus.  I like hearing and sharing his Holy Name.

Friday, August 18, 2017

TGIF Aug. 18, 2017

I'm sitting outside at a picnic table after a busy morning clinic.  I'm tired out by confrontation.  Hassle and demands for special treatment. Chipping away at a person. Working the room.  All the metaphors for the 'cut me some slack', 'you don't understand', 'just this one time', 'I really am your friend', 'you don't care', "my child, mother, aunt, sick someone, dog, cat etc story', the countless explanations we've heard a thousand times and used ourselves. I'm jaded. But I'm thankful for the one in 20 ratio. Everyone else was just perfect. The loud obnoxious one gets your attention but the 20 people were really just great. It's a 4 hour sometimes more experience. I'm exhausted by the strangers but the motorcycle ride is a wonderful experience. I often take the Harley on Friday.
Now I'm waiting for Laura.  Gilbert was ecstatic to see me when I got, lots of jumping and barking and bringing me toys.  I like his company but also like to leave him when I'm only going to be gone for a few hours.  He rides on the motorcycle but getting the box on and off is just a little hassle, not bad for a trip or a whole day but a nuisance for a half day. He's lying now sniffing the air and enjoying his place at the front of this 'territory'.  He's on guard and really in the know about what's going down here.
We had the police here big time a week ago. Several cars and guys like swat walking around looking for someone.  It was tense.  Then Laura learned about our friends being back together. The community news. I like the folk I meet. Laura always seems to know more about what's going around and she's hardly here.
I eat and read and watch tv and do a lot of paper work, evening writing reports.  Still doing the 80 and sometimes 120 hour work week if I include the research and reading.  At the end of the day I'm well paid but wonder if I ever do more than minimum wage with all the hours.
Looking at upgrading the RV.  It was originally for hunting and camping but I've been living about like I did with my yacht, sometimes doing the apartment thing but doing more hanging out here than I have in the woods.
"It's your home," Laura said.  I realized it really was and Mac explained to me the down payment and mortgage on units. He's living beside me in a really nice home. With Laura over most weekends I thought really I could use more room. And this last year with the office move and the switching over to clinics, loss of cleaning lady, and general chaos with deaths and grief and general survival mode I realize this is not a home anymore. Gilbert and I have barely survived this year.  He lost an eye.
The hot sunny summer has been a good time of recouping. Again IDAA was restorative. But I think about the long rainy winter and how claustrophobic it gets in this small space. I really have to consider a change. I don't want to do apartments.
With the Liberal government and Justin Trudeau increasing communist dictatator moves makes me want to leave Canada, move to the US where there still are States where people aren't into Identity Politics and Left Wing Violence.  I just don' t want to die in a Communist jail. The liberal's have outlawed freedom of speech already. The CBC News is constant propaganda.
After owning homes in the past I don't want to move and buy a house anywhere in Canada because I don't believe Canadians own houses. They lease them from the government who tells us what we can do in them. Better to rent but the neighbours I've known are increasingly all powerful especially  some raging addict who holds whole buildings hostage while lawyers protect them. Always it's the fallacy of  the 'ends against the middle'.  I'm a "middle" and no one cares for the Middle any more. I don't feel safe since I've heard from so many dozens of people stories of their unholy dangerous loud and threatening neighbours. Laura's tales of her 5 am partying neighbours with their  loud music   turns me right off the overpriced Vancouver apartments. In my last apartment I had to deal with a delusional man myself.  Just one of many colourful neighbor tales. It's its own genre like the mother in laws.
But politics is foolish.I'm irrelevant to all the Gods of Washington and Ottawa. Victoria doesn't really  care. Our own Mayor is only interested in bike lanes so generally I don't know why I've been allowing myself to be distracted by politics.
I've been arguing on Facebook with the lying violent left wing commies and the deceitful Islamic terrorist  hoards and I don't know why.  I really should mind my own business. I really like the .Conservative Party with Andrew Sheer, Michelle Remple and Candice Bergen.  Their saniety is too often blocked out by the selfie dominated loud Liberals with all their lies and corruption..
 Other than that I can only explain myself by saying I'm afraid of Justin Trudeau's abhorrence of all I think of as Canadian , essentially Canadian values. I really liked Kellie Leitch and am not convinced that Andrew is as strong on Canada as Kellie was.  He's got a good group around him and I really hope they get rid of the pustulent smegma of a stony eyed leader we have right now.  I ought not to be so invested. I'm really not being diplomatic in my astute observations.
Trudeau is everything I was when I was smoking dope and drinking wine and talkin left wing intellectual nonsense as an effete university professor dilettante with a pretty wife who came from an alcoholic family and was so traumatized by that background she'd do anything to avoid trouble. I was trouble eventually. I questioned the lies of the main stream media. I treated too many alcoholic senior media and heard too many stories of pedophilia and broken laws and then I kind of grew up seeing the world through hard experience and learning that the 'platitudes' were just that.
But Dr. Kaufman gave a talk on Civility and he's an okay guy and I really have to be more civil on Facebook when I'm talking to a brain dead walking genitalia whose trying to spout off about politics and he doesn't think his farts smell. I have to resist calling the cretin wasted DNA just because he's a thorough idiot. I must be civil.  I am so tired of their trying constant strategizing and their persistent moving the bar and insisting they want me but their inclusivity only applies to my being exactly like their cookie cutter reality.
I'm ornery today. I had to prayeon the motorcycle because I was having flashes of doom and gloom. Then I realized it was just because it was a cloudy day.  I was having flashbacks to the coming of winter and wondering how I'd live through a mother season of misery.
If I get better digs maybe the higher ceilings more room and less dirt and clutter will stop me from begging Trudeau for the euthanasia he wants for my kind of people, English Canadian westerner, third generation.
I've done gratitude lists too.  Thank you Lord Jesus for your sacrifice and resurrection, for your teaching and being, for the Christ consciousness in the very fabric of creation for the example of humanity. Thank you all my teachers for the direction and concern and guidance you have given. Thank you for the beautiful loving sexy women in my life. I have truly been blessed even when they've interfered with my escape and made me pay a huge ransom to get away from their taking me hostage. I really am thankful for Gilbert and my motorcycle and my friend Laura who Gilbert and I are waiting to arrive.  He takes me for granted but really has her twisted around his little paw.  Right now he just visited for a bit for a scratch and has begun chewing on his Snoopy toy.  Different days he has favourite different favourite toys.

Thank you Lord for this existence. Thank you for electrons and neutrons and photons and Higgle particles and galaxies and stars and the sun and the moon.  Thank you for the breath and my heart and lungs.  Thank you for my taste buds, scent, stomach, skin and genitals . Thank you for my hands and feet. Thank you for the internet and key boards and discoveries and inventors and genius. Thank you for Ginger Ale. Thank you for porcelains. Thank you for barbecue. Thank you for food.
Thank you for clothing.
Thank you for the Church. Thank you for 12 step programs. Thank you for the university. Thank you for the clinic. Thank you for my teachers. Thank you Ford and Mazda and Harley Davidson.  Thank you for my F350 Lariat Edition 4x4 truck.  Thank you for choice. Thank you for movies. Thank you for ballet. Thank you for theatre.. Thank you for concerts and thank you for music.
Thank you for sex. I really enjoy regular orgasms and love making and just plain doing it.
Thank you for bikinis. Thank you for beaches. Thank you for shorts and sandals in summer.
Thank you for the dress pants I found under the winter clothes. Thank you for jeans. Thank you for bows and arrows and fishing rods.
Thank you Lord . Thank you Jesus.  I really want to read and study the Bible more. I'd like better internet coverage so I can do more Hebrew study. I wish that I'd learned Gaelic. Thank you for conversations with Ted about the Celtic calendar.  Thank you for history and old ways and traditions.
Thank you for the Irish and the Scottish. Thank you for the Hay Clan.
Thank you for swords and rifles and pistols.
Thank you for the kazoo. And harp.  And violin. And my guitar. I enjoyed playing my guitar. If i had a larger home now that I no longer have an office I'd have my guitar out like I did there. I'd not played it for months till this week simply because it's in storage like so much stuff. I 'ld like to be less cluttered. I'd like the organization new digs would bring and after these last couple of years of pain it would be good to rebuild.
Please Lord removing the lying delusional threat that plagues me. Protect my life and my dog's life. I've had too many threats and I've just been doing my job as I was taught but with people who are borderline and psychopathic and now they have such institutional power to harm and be offended and to suck the very life out of existence. Canada is plunging into the despair and depression that is the norm in communist countries.  The Worker's paradise.  The corruption tires me.
I must have hope and optimism. It's the end of a week. I'm weary.  All day with despair and sickness.  Days of complaints and more and more the front lines takes the abuse and the layers upon layers of high paid Monday morning quarter backs is amazing. No one wants to see patients any more and everyone is angry that I can't see them yesterday and furious that I won't see them today and tomorrow. The system of care is imploding except for those with government and union and corporate benefits and special insurance. The tiers increase but I'm okay. I've been blessed. I not one of the millionaires who own homes in Vancouver where every actual home owner is among the wealthiest on the planet but I'm okay.  There are 9 billion and most every Canadians is in the upper 1 billion. The severe poverty now is limited to less that half a billion, maybe a tenth of the people on earths. A mere hundred or so years ago nearly half the world was in poverty and facing disease. Life expectancy is increased dramatically.
I am truly blessed.  Enough rambling. Thank you Lord for Friday TGIF!!!!



Wednesday, August 16, 2017

Gratitude Wednesday

Thank you for Gilbert Lord, my furry little friend and companion. Help him keep his sight in his remaining eye.  Thank you for the blue sky this morning.  Thank you for the music of the two alarms that woke me, that diddly and the space ship sound.  Thank you for clothing that slips on without fuss or fasteners, sandals, sweats shirts and hoodies. Thank you for the sun and rain.  Help keep the wild fires in the country down.

Thank you for work which organizes and gives purpose to my life. Thank you for the gifts that have made me of service to you and my fellow man and woman and to children and babies. Thank you for the learning and reading and doing. Thank you for this program and this iPad and the internet and all my friends that are connected to me and each other through this advanced technology of today.

Thank you for my family. Thank you for my high school friends. Thank you for my university friends. Thank you for my friends of travel. Thank you for my friends of work. Thank you for my American, Canadian, South American, British, European friends. Thank you for my friends from Asia, and Africa.  Thank you for the opportunity in life to travel to all these lands and meet the wonderful people I have been truly blessed to know. 

Thank you for my physical reality, the place I live, this country, province and city. You know the countryside is God's country. This city is pretty funky too. So beautiful though so expensive. Help me to be able to afford to live here. Expand my territory.

Protect me from evil. Protect me from lies. Protect me from rapists. Protect me from theives. Protect me from bullies. Protect me from falsehoods. Protect me from psychopaths and sociopaths. Protect me from the banality of evil.

Thank you Lord for food and sustenanace. Thank you for the networks and history that has brought all this to us today. Thank you for entertainment and communication. 

Thank you for my breathing and the air. Thank you for my heart and the feelings. Thank you for the senses.  Thank you for my feet and hands and back and head and all my internal organs. Thank you for chemistry and biology and math. Thank you for neurology and pharmacology and intuition and help my patients with addiction. Guide them and keep them safe till they increase their motivation to change. Help us help them.

Thank you for sobriety and faith and peace and goodness. Thank you for my teachers and the healers who have helped me over the years. Thank you for my dentist Doug Lovely who exercised the demons from my lower jaw and saved whatever goodness he found in the war on decay.

Thank you for the men who are surveying my home and offering me the hope of a better place to live. 

Thank you for my friends in program. 

Thank you for my boat and vehicles. Thank you for the joy of driving. Thank you for the music too Lord. I've been so thankful for the music this summer. Thank you for memories. Thank you for the novels and treatises and reading.

Thank you for all your blessings Lord. Thank you for this planet, this universe, the waters and filament, the people, the animals the flowers and trees and bushes. Thank you for the galaxy and the hope of space travel. Thank you for this dimension and the hope of multiple dimensions. Thank you for you son Jesus and all the prophets and saints and mystics.  Thank you for all true religion.Protect me from false gods and false news and lies. Thank you for reality and truth and Martin Buber, and Camus, and Kierkegaard and Bonhoeffer and Brother Lawrence, and St. Theresa and St. John of the Cross and Yogananda and Buddha and the Tao and the Flow and Jung and Freud and Leonard Cohen and Martin Luther and Gandhi and Churchill and Robertson Davies and Kohut and Kernberg and Erickson and Grossman and O Henry and Shakespeare and Kidman and Clint Eastwood and Jason Strachan and 007 and Arsenault and Ray Bradbury and Spielberg and the Beatles and Country Joe and Lightfoot and Dylan and our prime minister Justin Trudeau and the Queen and Donald Trump and Australia and Jurd and Hugh and Darryl and John and Art and Tom and Adam and Carole and Bobbie and Archie and Wes and Opera and Ballet and great Art and Monet and Hagen Dax and true Culture, great Culture, culture of culture , the best of the best of all people, space flight and brain surgery and cures for diabetes and antibiotics and anti vitals and cures for cancer and weather balloons. Thank you for all the wonders of the world and all the man made wonders.

Thank you Lord.  Help me through this day and watch my anger, my impatience. Overcome my potty mouth. Help me to be less a barnyard animal and walk more upright if that is what will help me in my communication today. Catch me putting on airs and distancing myself. Help me to meet people where they are. Help me not offend those constantly looking for offence. Help me to be safe. Protect me from patients bringing guns and knives to the office and threatening me. Protect me from patients who use lawyers as weapons. Protect from patents who abuse the system and use beurocrats as weapons. Protect me from weaponized words.  Protect me as a Christian from persecution. Protect my Jewish friends who increasingly face persecution today no different from the persecution they experienced from the nazis.  Protect us all from the new nazism which is covert as most aggression today is covert and black is white and whiter is black. Protect us from the abuses of the elite .  I pray for the Elite that they may do what is best for all and help the world as a whole and care for all the people including me.  May we have greater gratitude individually and collectively.

Help me Lord with my character defects. Help me to overcome my lust, sloth, gluttony, envy, anger, and those other two. Help me follow the 10 commandments. Help me to do unto others as I would have them do unto me. Help me be a good example. Help me to be more the man my mother raised me to be. Help me to be more like my father and brother before me. Help me to be less afraid Lord. Help me to fear less. Help me to have faith in you and greater perception of the Good.

Thank you Lord for Freedom and Choice and thank you for helping me walk in the light. Thank you for the sunshine today.  Thank you for the warmth and breeze. Thank you. 



Wednesday, August 9, 2017

Smokey Vancouver

Another morning of smokey skies and thick air. I slept well and am thankful for that.  Last night breathing was difficult and the day was long with stress.  Leaving for a few days as a doctor the work just piles up.  Calls upon calls for services.  Desperation and waitlists.  I avoided the coroner's file yesterday.  Death deserves time. I didn't recognize the name. A new person I hardly knew. Like the young girls a few months back.  This Chinese Fentanyl is a plague on youth.
I remember the sky like this years ago.  The smell of smoke and the haze was there too.  They say the wild fires were worse years past but this one is bad.  A bad year.  So many places we hunt are destroyed.  Nature's purification.
North Korea threatens Guam. My friends live there. I visited. So close to Saipan. I'd fly over.  Islands in the vast beauty of the Pacific. Chamorro people and Carolingnians.  I miss the laughter at times. The white beaches. The magnificent underwater caves. Such pristine places for tourists and those who live there.
Amaniac threatens to bomb them.  God I hate these aggressors.  Of course they all say they're victims.  ISIS in the East and North Korea in the West complaining they are victims just as Hitler did when he invaded other lands. The Japanese said the same.
There's rain promised for the weekend. I'll like the cleansing but frankly, I love the sun and heat.  I have loved this summer and the back yard and walking the dog and lawn chairs.  Some years I've spent the summer sailing.  Other years I've been camping. This year it's lawn chairs and back yard books.  I just finished a Thriller by Brad Thor , Use of Force.  I am reading the History of the Early Church but along side that serious read I've these other more exciting novels which just seem to take over my interest. Little progress on the neuro chemistry of the brain book I'd picked up too.  Lying in the sun I'd rather escape to swash buckling tales of young men and sexy women travelling all over the world to exotic places to save the world from what ever, terrorists, aliens or catastrophes of other kinds.  Joseph Campbell's Hero Tales. The stuff of adolescence.
I must go. Work demands I come in early.  Gilbert has had his eye medicine and treat.  We've walked. He's eaten. I just need to shower and dress.  Morning is a series of routines that must be completed. Not necessarily in order. I've had my coffee.
I'm prayed.  I 've not meditated long enough .  Be Still and Know that I am God.  I'm not prayed long enough. I've not exercised enough. I've got that perfectionism bat I beat myself with. A whole series of expectations that threaten to grow to resentments. I love weekends where there isn't the deadlines waiting to suck the soul out of one. I'm thankful though for the dead lines. The meaning in life is serving and helping and I felt good to be back at work.  There's times when it's just good to be the automatic.  We ask the questions, write the scripts, look up and say a kind word, give encouragement and set another time.  Completing intakes, forms, assessments.  I was slow first day back, distracted by a multitude of phone callls.  I've bills to pay and had no cheques or envelopes. I put these in last night.
I am thankful for God.  The idea of a loving universe, the idea of an intrinsic meaning and purpose, these are important to me. I believe that if I do good and serve I am planting good. I am at an age where disease strikes readily. I'm thankful for my health.  Each day I read of those close in age or important to my youth dying.  I didn't know Glen Campbell was in his 80's but he's died and I loved his music growing up.
Aging is a factor. Thank you Lord for this life and this aging.  Gilbert and I had such fun with Laura on Monday.  What a great companion. Life was so much brighter and fuller the three of us rolling about.  Gilbert must get in the Center and be included in our hugs which then become a free for all.  It's hilarious.
I'm resisting getting up.  All I've got to do is shut this down and go to the shower.  Shave.  Dress. I sometimes have to speak to myself to get through the routines to get out of the door.  There are dragons out there.  The traffic is a trial.   But once I'm at work it's fine.
Must go.
Thank you God for all your blessings. Watch over my family and friends. Keep them safe and well today. Help me be an instrument of your love. Help me to serve my patients and colleagues well. May I do as my teachers taught me and be compassionate and kind in my encounters. Yesterday I was so overwhelmed so behind in time that I forgot all the Dr. Kauffmen taught about civility.  I would have been more civil if I wasn't so harried but I didn't get angry or impatient.  But I did talk over some and I didn't wait to listen longer. The person on drugs will talk forever and I don't want to listen to the drug talk but I didn't cut them off though perhaps appeared impatient.  The waiting room was angry and loud.  I felt pressure all day. No lunch. No coffee. I needed to pee for hours before I couldn't hold it.
It's hard to come back to work after a break. But it's a short week.  More new demands this week too but this too will pass. I want to get on with getting my new home. I talked to Mac about ways to transfer belonging for old trailer to new. Logistics. It was great to see Dave and Marcia back together on his motorcycle There are money matters that need addressing and sharks are circling always,  I 'l let out a reef in the sail and move on with the day.  This too will pass.
Thank you God. Thank you Jesus.