EIEIO – Graphic Medicine in Old McDonald’s Classroom

Screenshot: Graphic Medicine website header

Screenshot: NLM Exhibit: Graphic Medicine: Ill-Conceived & Well-Drawn

[NOTE: First published at https://slowchathealth.com/2022/05/13/eieio-graphic-medicine-in-old-mcdonalds-classroom/ ]

At GraphicMedicine.org one of the first things you’ll see is the definition: “Graphic Medicine … explores the interaction between the medium of comics and the discourse of healthcare.” The Graphic Medicine exhibit at the National Library of Medicine (NLM) opens with: “Graphic medicine is the use of comics to tell personal stories of illness and health.” So, comics, cool, yay! But healthcare? That can get tough, as you know. It’s not easy having mental health challenges, a chronic condition, living with pain or a disability, just feeling like you’re different from the people around you. It’s not easy talking about it, especially when you don’t see anyone else around who is like you. There are also topics that are just … difficult … for almost everyone! (Ahem, sex?)  

Engagement & Discovery

One of the superpowers of comics and graphic novels is the way they draw the reader into the story, and make content understandable that is difficult to put into words. For teaching health, using comics seems obvious, but first, does the content you need to teach already exist? To get started, here is one on teen pregnancy from Indigenous Story Studio. School Library Journal has a good starting selection, and so does the Network of National Libraries of Medicine.  Of course, always ask your friendly neighborhood librarian for more ideas. 

Information, Issues, & Awareness 

Is there a hot news topic you want to teach? The Nib is a comics journalism site that includes short pieces on health topics. We Need Diverse Comics is great to finding comics content on social justice topics. There are comics ranging from mental health to disability, how people respond to gun violence, anti-racism, police brutality, and so much more. Specific health topics available in comics for middle school and high school include sex education, anxiety, asexuality, cancer, diabetes, food, more mental health (and more cancer), and even pieces around what life is like working in healthcare professions. Choose excerpts carefully, as not all are age-appropriate. Comics anthologies can be good sources for short pieces you might select as a prompt for awareness or a class discussion, and many comics artists are putting short pieces on Instagram, like CancerOwl. YALSA has a great list with many examples, expanded yearly (2021, 2022).  

Enrichment & Visual Literacy

Comics are known for being engaging and accessible, but this is more true for some than others. Our culture is shifting toward visual and multimodal literacies, and comics are part of that. Helping kids learn to work with and critically examine visual content adds extra importance to the content. Brian Fies’ book, “Mom’s Cancer” is a personal favorite for examining how visuals communicate content differently than text. Some of the questions you might pose for a class or an assignment could include: 

  • How do the colors impact your reading or support the topic? (compare the use of red in Dumb and Go With The Flow)
  • Where is the artist drawing your attention in this panel/frame? 
  • How does the style communicate emotion? (Compare Haines and Brosh on anxiety)

Investigation & Analysis

Here are a few assignment or project ideas for applying critical thinking approaches to 

  • Write a review of a title. 
    • Is it accurate, both medically as well as telling an honest story? How do you know? 
    • Who wrote it and why? Are they trying to inform you or persuade you or something else? 
    • Do you agree or disagree? Do you have a family or personal experience with this topic? Does that change how you read it? 
    • Do you like or dislike the art style? Does it work or not, and why? 
  • Do a deep dive into a single page or frame analyzing how visuals support the message
  • Do the words and the images tell the same story? 
  • Create a response to some aspect of the work being read, and provide evidence for any health claims 

Original Works & Creation

Sometimes there are students who want to make their own comics. There are prompts for assignments from 1-6 panels. When it happens, I’ve found team approaches and co-creation really powerful. First, they allow people who are good with words and those good with art to collaborate and both work from a position of strength. Small groups also work well, developing a consensus story around a topic or issue. Try having two different teams draw a scene from different perspectives (eg. doctor/patient), and then discuss how they differ and why. 

Prompts: 

  • What do I wish … 
    • … my doctor/HCP knew or did different? 
    • … my parents or family understood? 
    • … my friends understood about your health (physical or mental)? 
  • When I [X], it feels like this in my (body, mind, emotions) 
  • In this scene, show each of the five senses
  • Once upon a time, [X] happened

(un)Diagnosed: Day 731 (24 Months, 104 weeks) – Happy COVIDversary (Da Brain iz BACK)

Proof of a functional brain. Grid of screenshots showing successful game play results from Wordle, Numberle, Chordle, Quordle, and Wordle. The images are dark mode, with gray, yellow, and green on black.
Proof of a functioning brain?

Today is 2 years since that first distinctive tickle in the back of my throat that heralded in a small way what was coming. That was the day then-President Trump declared a national emergency for COVID-19. Now, that strikes me as having a peculiar irony, but I’m not sure why, precisely. It’s almost like a gong was ringing, and I couldn’t hear it. I remember thinking, “Whatever happens, we’ll be okay. We’ll figure it out. Take a deep breath and just keep going.” It was sort of true, in some ways. And, in a lot of ways, it was really far away from true. COVID-19 and I have kind of grown up together, I guess, in a sense. Do we call this good enough? 

In the Long COVID / COVID long haulers / people with PASC communities and support groups there is a special bond between those who identify as first-wavers. None of us expected to still be sick, those of us who’ve made it this far. I particularly didn’t. I looked at the research of long-term sequelae after the first SARS-CoV. It was easy to find back then, because there was so little on SARS-CoV-2. Now, I just went back to try to find that early research I’d consulted, and it’s almost impossible to sift through. For example, there are over twelve THOUSAND articles in PubMed when searching for “SARS sequelae.” If you add a date limit to find those before 2019, there are fewer than 400, and most of those were written in 2003-2005. That’s intense. Surreal. What I remember now of what I found then is that there clearly was something similar to Long COVID. Most of the folk who developed this after the first SARS recovered within a year, most of the rest recovered with the following year. By the second anniversary of the initial infection, 1% or less were still ill. I was counting on that. This whole time, I’ve been counting on that. I was determined to be one of the folk who recovered fully by the end of year one. Then I wasn’t too worried, because I still had year two before I should be worried. Right? Right. I told all my rehab folk not to worry, because I wasn’t worrying; I was going to be one of the folk who recovered.

I actually was recovering really well for a while. I’d tracked all the research and recommendations from other countries who were ahead of the USA in figuring this out. I went to my docs early on, and shared what I was finding. We got me the dysautonomia diagnosis faster than most folk are getting it even now, for those developing problems from Omicron infections and other recent varieties. I was able to get a referral to neuro-rehab pretty early, and that was showing good results for people. It was painfully slow, but it helped me make progress, too. Neuro rehab had a goal for tolerated activity levels that would have permitted me to go back to work in the office: 5,000 steps a day, 7 days a week. If I could do that, I could do most (not all) of what I was doing before I got COVID. I was at a point where I was walking 5,000 steps or more 3-4 times a week. Last May, I was looking at the light at the end of the tunnel, and getting excited about going back to work.

I’m going to skip part of the story, so I don’t get into trouble, but the short version is that I was persuaded against my better judgment (by persons involved in my treatment planning but outside my medical team) to switch rehab. The new rehab place had been misrepresented, didn’t have the kinds of resources available where I had been going, especially not staffing, and within a month of starting at the new rehab place? I’d been knocked back into a major relapse, starting over from ground zero. It was bad, really bad. I tried to switch back to my previous neuro-rehab. I finally got back in four months later, and then insurance decided they wouldn’t cover it. I’ve been left pretty much to my own devices since then. Skipping a bunch of nitty gritty details I’m sure you don’t really want to hear, I’m now back up to 2000-3000 steps 1-2 times a week, and most important, the brainfog almost completely went away last December. It was a special day when my boss said it was like talking to the before-times me. (See the opening image for my bedtime ritual. Many long COVID folk are playing games for a kind of self-prescribed DIY cognitive rehab / brain retraining.) Being impatient, I’ve been trying to go back to work in the office anyway. Once in December. Once in March. I’m determined, I’m going to get there.

As far as counting my recovery progress, I’m now counting from the relapse, not from the initial infection, so I figure I’m going to be pretty much fully recovered by this time next year. That’s the plan, anyway! Meanwhile, I had some conversations with folk who were also diagnosed with dysautonomia, and who said they were able to recover fully within, oh, about eight years. I’m seeing people with long COVID who got it after me, and have recovered. Folk teaching yoga classes, folk working on busy hospital wards, folk traveling internationally. All those folk were as sick or sicker than me, so there absolutely is still hope.

A lot of the folk who aren’t recovering weren’t as lucky with me for having access to information, diagnosis, treatment, etc. It’s just dandy for docs to tell folk they need to wear compression garments, but if they aren’t covered by insurance and they lost their job while sick with COVID, how are they supposed to get them? Ditto electrolytes. People who are now without income are being told to drink a half gallon of more of electrolytes, and they can only afford a pint or a quart a day of whatever sports drink they know probably fits the bill. No one is mentioning to them that they can make this at home, and giving them a recipe. Many folk have challenges with memory and executive function now, meaning that telling them something and pulling the brain together enough to make it happen are completely different things. Pacing is another critical concept that isn’t being mentioned to many of these folk, and over the counter things to consider trying, like anti-histamines. So, pardon me, but I’m going to drop a few (highly selected) links down at the bottom of this post for folk who aren’t sure where to start. And if anyone knows of a swapmeet / mutual-aid type of resource to share compression garments that didn’t work for the original owner, please let me know, and I’ll help spread the word.

LONG COVID RESOURCES

General

Long COVID Physio: https://longcovid.physio/quick-access

Long COVID Support (UK): https://www.longcovid.org/

Long COVID Support (UK): Resources: https://www.longcovid.org/resources/patients

World Physiotherapy briefing papers: https://world.physio/covid-19-information-hub/long-covid

Twitter thread of Long COVID Guidelines (start here): https://twitter.com/pfanderson/status/1465440816349028356

Helpful for Many (but check with your doc)

Dysautonomia & POTS

Dysautonomia International: For Patients: https://www.dysautonomiainternational.org/page.php?ID=36

Dysautonomia International: General Information Brochure on Orthostatic Intolerance and its Treatment, by Dr. Peter Rowe https://www.dysautonomiainternational.org/pdf/RoweOIsummary.pdf

Pacing

#MEAction: Stop. Rest. Pace. https://www.meaction.net/stoprestpace/

Long COVID Physio: Pacing: https://longcovid.physio/pacing

Post-COVID-19 Interdisciplinary Clinical Care Network: Fatigue in Post-COVID-19 Recovery: Pacing: http://www.phsa.ca/health-info-site/Documents/post_covid-19_fatigue.pdf

The Why, When and How of Pacing | Long Covid’s Most Important Lesson https://www.youtube.com/watch?v=gUPvNwvkOlA

Your COVID Recovery (UK): Managing Daily Activities: https://www.yourcovidrecovery.nhs.uk/your-road-to-recovery/managing-daily-activities/

Recipes for DIY Electrolytes & Oral Rehydration

Dartmouth-Hitchcock Comprehensive Wound Healing Center: Oral Rehydration Solution Recipes: https://www.dartmouth-hitchcock.org/comprehensive-wound-healing/oral-rehydration-solution-recipes

University of Virginia Health System: Homemade Oral Rehydration Solutions: https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2021/01/Homemade-Oral-Rehydration-Solutions-9-2018-1.pdf

Ten Tips for Being a Patient

Photo of a large red button labeled with the text "Push for Help."
Flickr: RosefireRising: In the Doctor’s Office — Push for Help

I was asked for what I tell people before they see a new specialist for a new icky diagnosis. My top ten tips for being a patient.

1. Bring a friend with you. They’re there to support you, to validate your story, to listen and hear things you might not notice, to provide a second perspective before/during/after.

2. Take notes. At the very least, date, time, place, who you met with, what questions were asked, what answers were given, what tests were taken, and how to find the test results. (This is especially necessary if you are in a crisis situation or the emergency room, but it’s hard to do under those circumstances. Make a habit of it now, and it will be easier to do when you need it most.)

3. Who else can help take notes? Ask the person who comes with you to take notes for you. You’ll have a hard time remembering, no matter how brilliant your memory is. You may want to ask if you can record the conversation to listen to again later, but a lot of healthcare folk are uncomfortable with that, and they don’t know you well yet, so if they say “no” it’s really not a surprise.

4. Ask the doctor to write out or spell words that are unfamiliar to you. Also ask the doctor for alternate words that describe the same idea.

5. Have a list of your questions before you arrive. Prioritize the questions. Pick your top three (because the doctor probably won’t have time for more).

6. Ask people for more question ideas. If your brain is frozen and you can’t think of what questions to ask, try searching, “What should I ask” or “top ten questions to ask about” with the name of your diagnosis. You might also try searching “new diagnosis” with the name of your diagnosis.

7. Use questions to engage & build trust with your doctor. When you do research in advance, some of it will raise questions. If you bring in info to ask about, try asking your doctor questions like, “Is this good information for me? Why or why not? What would you recommend instead or in addition?”

8. Ask the right question for the right doctor. Keep in mind that you’ll probably see a whole bunch of different health care folk, and not all of them are good at answering all questions. If you aren’t getting the answer to a question that is helpful for you, ask “Is there someone else of whom I should ask this question?”

9. Read the fine print, and read your records. If you need extra time to read it or think things through, you should have the right to take whatever time you need. You also have the right to ask for copies of your medical records, and there shouldn’t be a charge, or only a minor charge. If you don’t have the time or energy to read your records (I totally get it, it’s exhausting), do you have a trusted friend who can help you review these? Mistakes creep in under the best of circumstances, and things go better when you catch errors quickly.

10. Find a patient support group with people who are kind and generous. Being angry is completely okay as long as they don’t get stuck there. You don’t want a group that spends a lot of time censoring discussion, but you also don’t want a group that lifts up misinformation. It’s okay to join different groups until you find the right one for you. You don’t have to talk. You can lurk until you feel comfortable talking. You can search the archives to see if someone else already answered your questions.

Most of this is in the book Nancy Allee and I wrote 20 years ago — Medical Library Association Encyclopedic Guide to Searching and Finding Health Information on the Web. There you go — this is the Cliff Notes version.

(un)Diagnosed: Day 550 (18 Months, 78 weeks) It’s not over until it’s over … 

A square of white notepaper on a dark blue fabric background. The notepaper is folded into quarters, and in each quarter is roughly sketched an eye. Top left: a colorful eye with a rainbow iris; top right: a gray eye surrounded by purple, blue, and green; bottom left: a half closed eye showing lavender whites and surrounded by thick gray; bottom right: a closed eye.
A sketch I drew of Long COVID for a workshop during the Graphic Medicine Unconvention, August 13-15.

It’s been a while since I did one of these updates, and a lot has happened. And nothing has changed, or … at least it feels like that some days. Today it is 18 months since I developed the first symptoms of COVID, 500 days. It’s starting to feel like … forever. It’s funny, because I was so hopeful and determined for so long, and now I’m not. I’m much better, but part of me is giving up. The closer I come, the farther away ‘normal’ seems.

The drawing at the head of this post is one I drew during a workshop for the Graphic Medicine Unconvention. I have hand tremors now, better some days, worse other days, but the quavering in the lines is that, the tremors. It made it hard ro draw, and I wasn’t sure I could draw anything at all, because the tremors were pretty bad that day, but I decided I could draw cartoon eyes. I grabbed felt tip markers, and tried. Expert storytellers say to start your story before everything changed, when things were normal. That’s the first eye — all colorful, bright, vigorous, full of Spring and colors and energy. The second eye shows the early months, the acute COVID phase, and the first many months of the long COVID experience, when I was constantly bitterly cold (except at night, when I was burning up). I cut my hair extra short in December, but no one noticed until mid-summer, because that’s when I finally stopped wearing winter hats indoors all the time. The third eye is half asleep to show the fatigue and brainfog. The last eye, the fourth one, is closed, just a few chicken scratch black lines, to show both the extraordinary amount of time I spent sleeping over the past many months, but also the times I just wanted to die. I’m pretty sure I’m past that, or I wouldn’t be mentioning it, and let me tell you, my family is more than ready for that part to be done, but when I drew this it was still a far too vivid memory.

In some ways, I’m a lot better now. In some ways, I’m not. I’ve just been approved for a graduated return to fulltime work. I’m supposed to be back fulltime in two weeks. Cognitively, I’m ready. Brainfog is rare now, and I’m cognitively more clear than I was even a couple months ago. My cognitive endurance is much better, and when I push things too much, I bounce back faster.

Physically, I’m not remotely ready. I was almost ready in June, but then there were some problems with my being switched to a different rehab program to speed up the process, and instead it knocked me back several months of progress. It’s a long story, and I don’t want to talk about it, so don’t ask me. It’s enough to know it was bad, really bad. At the time, I was walking about 4500 steps a day. Nothing like the 11,000-12,000 I was doing before COVID, but enough that I could probably get to and from the office on public transit. I felt great. I felt like I had so much energy. I was so hopeful. After the crash in early July, I was knocked back to 700 steps a day, and I spent a month crying every day at some point. Pacing is absolutely critical for Long COVID folk like me, with predominantly neuro symptoms. Part of pacing is figuring out your warning signs. After this crash, they all changed. I couldn’t tell how to know when I’d done too much. I felt really lost. Things gradually started to return to something I recognized, but it took a long time. After two months, I’m now up to about 1500 steps a day. This is not enough to get me to the corner drugstore and back safely, but I’m working on it, and hopefully in a few more months, I’ll be back to the 4500, and able to try to go to campus again.

Okay, enough of that. It still looks like I will eventually recover to a level that will allow me something resembling a normal-ish life. I remember telling my neuro rehab therapist during the first appointment, “I want it back. My life. I want it ALL back!” I wouldn’t say that now. I do think I’ll get back to everything I used to do, just not at the same level or speed I used to do it. And there are silver linings. I used to have an uncontrollable vocal fry that made me have to stop singing, and the treatments I’ve been doing have given me back part of my singing voice. Not much, but at least I can enjoy singing in choir again. I’m grateful for that!

Overall, healthcare doesn’t know much about COVID or Long COVID, but they have learned a lot really fast. There is more coming out all the time. As you might imagine, I’ve been keeping an eye on this. I’ve been collecting a lot of clinical guides, best practices, interviews, etc. I’m going to put those in a post, but not this post. In a few days. I have all sorts of goodies to share with you!

Long COVID in the News, Good or Bad? A Case Study

Screenshot of the WKRN article on easy long COVID diagnosis which is  linked in the blogpost.
I started here, with the WKRN version of the article, trying to answer, is this good information?

What is the problem here?

Y’all know I have Long COVID, and of course, I’m in several online support groups. Last week I saw a whole spate of news articles with titles along the lines of “simple blood test can tell whether patients will suffer from long covid.” That would be really nice if it was true, wouldn’t it? To me, it sounded too good to be true.

As a librarian, you kind of build up instincts around the information pitched at you. We all sometimes get it wrong, and I don’t always have the energy or time to check out a piece before I post it. Sometimes I post things so I can come back and look at it later. Sometimes I post things I don’t trust just as an example of how bad things can be. I warn people that my posting a link doesn’t mean I endorse it. Sometimes people push back and educate me about how bad something is, and I’m grateful for those conversations. Sometimes I post something and say, wow, this is really bad, and then bots come out of hiding and jump on the post, trying to trick me into getting a conversation going. (That happened last week, and I ignored the ones that used polite language and reported and muted the ones that didn’t.)

Why does it matter?

For this piece, the first time I saw it, I didn’t have time, so I left it alone. It kept coming up, though, and other patients were saying they were going to write to some of the researchers mentioned and find out if they could get the test. There are so many horror stories I see in the LC support groups, of people whose doctors don’t believe them and won’t support them, of people who lost their insurance or their jobs because testing wasn’t available when they caught COVID and they were instructed to stay home, and now the people with the resources don’t believe they are genuinely ill. It seems that people with Long COVID fall into one of four groups: 1) those who tested positive by PCR, and have antibodies (a tiny minority of the community); 2) those who tested positive by PCR but never developed antibodies; 3) those who tested negative by PCR or couldn’t get tested but later were shown to have antibodies; or 4) those who tested negative by PCR or couldn’t get tested and never developed antibodies. Group 4 seems to be the largest group among the Long COVID support groups. Some of the Group 4 folk, like me, were lucky to have a clear documented exposure and were able to get a clinical diagnosis based on symptoms. Most are not.

People did exactly what they were told to do (stay home instead of getting tested or going to Emergency), and now they have been ill for months or over a year, and are suffering while basically being punished for having followed directions. By “punished” I mean they are being denied access to treatment, rehab therapy, specialists, time to rest, accommodations; their insurance is denying coverage; their doctors won’t refer them to treatment; their employers say they are faking it, and fire them; and they are being denied unemployment and/or disability because they are ‘choosing’ to not work. If you can’t prove you had COVID, you also aren’t eligible to participate in many of the research studies, and most of the important research studies on Long COVID are excluding the majority of the people with the condition, who were never able to get a positive PCR test, for whatever reason (access, ability, permission, timing, other). This creates significant flaws in the emerging research around Long COVID, because we have no path to discover what is different about this majority community of people with Long COVID who never tested positive, and we can’t learn if the treatments are different for them. Even more important, if we knew what was different about them, we might be able to predict who would develop Long COVID and protect them. Right now, the only way to be sure you won’t get Long COVID is to never get COVID.

You can see a test that could prove someone has or had Long COVID would open the door to services and resources and legal protections that many are absolutely desperate to receive. I attended an IOSH webinar last week on Long COVID and return to work in which one of the presenters, with deep emotion and expressiveness, said something like, “I don’t understand why we are requiring people to prove they had COVID before we will help them. They don’t want to be this sick.” But, for now, in many places, you still need to be able to prove you had COVID to get help, and there are people hanging on by the skin of their teeth waiting for a test exactly like the one described. That’s exactly the sort of audience that snake oil salesmen look for, desperate people, to take advantage and to find a way to monetize, either by getting them to pay for fake tests or fake treatments or through tricking them into loading pages of bad information stuffed with advertisements, or getting them to actually buy the things being advertised, or clicking through to pages that leave pieces of code on their machine that scrape information about them. Many people don’t stop to think that going for the best information isn’t just about wanting the good information, it’s also a security issue, and potentially a financial one as well!

Is it good, step 1: Who says so? Authorship

So, I wasn’t trusting this, and over the weekend, I took a closer look at the original posting I saw in one of my support groups, which was from a Nashville TV station. Not a source I would normally seek out for cutting edge medical information. Local news sources tend be absolutely brilliant at local news, and not so great with world news. WKRN got their version of the article from a place called StudyFinds, which has the tagline “Research in a Nutshell.” I found another copy of the article posted with substantial edits by the DailyMail in the UK, who at least tried to contact a few researchers to quote, but the DailyMail is, shall one say, not the most reputable news source in the UK? And a tad biased? Although they have been working on their reputation, a friend of mine from the UK still calls it the Fox News of the UK.

Curiously, the Daily Mail version of the article was published with a byline (Mansur Shaheen), the day after the StudyFinds version went live (if their posted dates are accurate). Daily Mail: “PUBLISHED: 17:52 EDT, 16 August 2021 | UPDATED: 18:14 EDT, 16 August 2021”; StudyFinds: “AUGUST 15, 2021.” I took a look and Mansur Shaheen published five articles last Friday for the Daily Mail. That’s a lot. I remember when I used to post five blogposts a week, and how exhausting that was. This piece was the last of four Mansur published for DailyMail on August 16. Yikes. Reading between the lines, it looks like Shaheen uses a strategy of finding pieces from other places and polishing them or revising them enough to claim authorship. That’s probably a really useful strategy outside of academia, but since I am an academic I can’t help but think what my profs would have said if I had tried something like this while in school, or what happens to researchers who take one of their own pieces and rewrite for another journal. This isn’t considered a strictly ethical strategy within the venues for high caliber evidence. It sure is taking me a lot more time just to do this one blogpost.

Screenshot of the four articles written by Mansur Shaheen for Daily Mail on August 16, 2021.
Screenshot of the 4 articles posted to the Daily Mail by Mansur Shaheen on August 16.

I’m still debating about whether Mansur Shaheen who writes for the Daily Mail based in New York City is the same Mansur Shaheen who is “Deputy Editor at SB Nation’s Pride of Detroit, Election Reporter for Bridge Michigan, Freelance Journalist,” but it seems likely. I don’t think this is relevant to the rest of the story here, but it just fascinated me to find a Michigan connection while working through this, and it speaks well of his work that Mr. Shaheen is proud of his work and has a strong online presence. But I’ve gotten sidetracked, and let’s get back to the Long COVID simple diagnosis article. In the StudyFinds version of the article the authorship is listed under the generic name of “StudyFinds,” but if you read the whole thing and go down to the bottom, you will find a contributing writer named Mark Waghorn. I couldn’t find much about Mr. Waghorn. There are a lot of people with the same name, several of whom are in high profile positions in other industries (finance, architecture, banking, sales, even a race car driver). I was able to find people named Mark Waghorn who are writers. They might be different people, or they might be the same person, I can’t tell. One is a playwright and another an automotive technical writer, but both are in the UK, so who knows? In any case, that I can’t find much about a writer of that name working in healthcare journalism inspires little if any confidence in the article.

Is it good, step 2: Who says so? Publisher

You can search that title phrase (“simple blood test can tell whether patients will suffer from long covid”) on Facebook and find several different news stations posting their own copies over the past week. All of these places appear to have gotten the article from StudyFinds, so I took a look into them. It’s a pretty good (as in well-camouflaged) click-bait news site, near as I can tell. I want to call them a fake news site, but that isn’t strictly accurate. They mix up a lot of true bits and pieces with hyperbole and misleading headlines and stuff the site full of advertising. They make it really hard to find the actual true bits and they make it hard to get off of their site. Their links keep pushing people to other pages on their site full of other ads. They farm these articles out via newswires where they are picked up by a lot of small local news sites. I’m not saying they don’t have some good information in there, I’m saying it’s hard to get to the good stuff and they are monetizing the audience and manipulating the reader to make more money off of them. This isn’t necessarily a bad thing, it just means you are getting what you pay for. They describe their mission as follows:

“StudyFinds sets out to find new research that speaks to mass audiences — without all the scientific jargon. The stories we publish are digestible, summarized versions of research that are intended to stir debate: We do not agree nor disagree with any of the studies we post, rather, we encourage our readers to debate the veracity of the findings themselves.”

https://www.studyfinds.org/mission/

So who are StudyFinds? This is where things got really interesting. My first step was to look for their “About Us” page, who they say they are, their stated mission, and who’s writing for them. They actually have some real journalists as authors, but they also had a bit my radar latched on to which said pieces picked up from newswires and pieces from people who prefer to go nameless would be posted under a generic authorship. Guess what? A lot of their posts are under generic attribution.

I dug a little deeper. In the footer for the StudyFinds site, the copyright line goes to a company called “41 Pushups, LLC.”

Screenshot of the footer of Study Finds, with the copyright statement "(c)2021 41 Pushups, LLC."

Is it good, step 3: Follow the funding

Most companies, well, most legitimate companies, try to choose distinctive and unique names, so that when you search for them, you will find them and not other groups or information. When you search “41 Pushups, LLC” you find an awful lot of articles about how many pushups make for a good exercise program. It’s hard to find the company, but, hey, I’m a librarian.

41 Pushups, LLC doesn’t appear to have an actual official web presence (which is curious all of itself), but they did register their name. It’s curious that StudyFinds was founded in December 2016, and that the company that “owns” them was registered less than a year ago.

Screenshot of the Bizpedia page for 41 Pushups, LLC as of August 23, 2021, showing a filing date of September 21, 2020 and a business address of "8 The Green, Ste A, Dover, DE 19901"
Screenshot of the Bizpedia page for 41 Pushups, LLC as of August 23, 2021

The address they are at is “8 The Green, Ste. A, Dover, DE, 19901.” There are a LOT of businesses at this address, or at different suites within the same building. The building doesn’t seem to be that big, but that’s because these are virtual offices. They have a legally registered mailing address in a state with desirable laws, and they can operate a business under those laws while in reality the company could be anywhere in the world. 41 Pushups, LLC appear to be one of the over 250 LLCs sharing a single virtual address in Delaware which are under investigation by the SEC.

Screenshot of the satellite view of the address for 41 Pushups, LLC shows the building near the intersection of South State and The Green in Dover Delaware. The building has a flat roof and appears to be barely larger than the crowns of the surrounding trees.
Screenshot of the satellite view of the address for 41 Pushups, LLC and over 250 other businesses.
Screenshot of Google Streetview for the address 8 The Green Dover, DE 19901 shows a 3-story brick building with windows and shutters on what appears to be a residential street with limited parking and many trees.
Screenshot of Google Streetview for the address associated with 41 Pushups, LLC and >250 other businesses.

Is it good, step 4: Who else says so?

So is the news article totally completely fake? Well, we don’t know at this point in the process. I tried to verify the authority and credibility of the author, the organization providing the information, and failed to find information that would do that to my satisfaction. I tried following the links provided in the article, and that wasn’t useful either. The next step is to try to verify the content of the article directly.

There are a lot of ways to look at this. I started by trying to find the researcher who is cited as having made the discovery, and this time that paid off. Sometimes it doesn’t. Sometimes it isn’t straightforward to figure out which of the people mentioned in the article are the person you want to find. In this the article, they quoted so many different people as having said different things, in the support groups, people were trying to contact any or all of them, or whoever was located near them geographically. Many of the quotes were taken from other articles, and were not necessarily solicited specifically for this piece. This means the effort spent to try to contact the organization or researcher will not only take up valuable energy for no purpose, causing harm for these vulnerable and exhausted patients, it will also take up time and energy for whoever receives the request for information who are likely to not actually know anything about this topic.

You can see some of my search process reflected in a Twitter thread I put together while I was feeling frustrated with all of this. I identified Mark Wills and Nyarie Sithole, both of Cambridge University, as joint researchers on this project, and looked for recent news with both names. I first found a local news report on the topic from Cambridge. Remember earlier where I said local news is really excellent for their own news? I won’t trust a Nashville local news report on science from Europe, but I will trust a Cambridge local news report about Cambridge discoveries. Even better was the next thing I found, which was an official press release from University of Cambridge.

Is it good, step 5: Who has the right to say so?

This is also interesting. You see, the official press release was published under a Creative Commons license. This gives other people the legal right to rework and republish. So far, that would make it seem like what StudyFinds did is legally if not ethically sound. However, there are several different varieties of Creative Commons licenses. University of Cambridge used a CC04 license: you can share and adapt the original, as long as you include “Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made.” None of that appears in the StudyFinds version of the article, at least as far as I could see. I had to close 8 ads before I could try to print a reference copy.

Now, this assumes that the StudyFinds version of the article was actually based on the official press release. What if it wasn’t? As I kept looking, I found an article on this from the NHS, the National Health Service for the UK, but specifically from the hospital involved in the research. This was dated July 18, the day before the U. Cambridge press release (July 19). What makes me think that this might be the original source is that the photos used in the StudyFinds version are the same photos used in the NHS version. There was no license nor copyright statement included in the NHS post. I know in the United States certain types of information produced by the government are created free of copyright. I don’t know if this is true in the UK, but with some more digging I found out about “Crown Copyright,” which sounds similar. I wasn’t able to easily discover if the portions of Crown Copyright which make some information free to reproduce and modify apply to NHS information, but I did find that some NHS organizations apply this to some of their information, with restrictions like these: “Permission is granted to reproduce in any format for your personal and educational use free of charge, provided it is reproduced accurately and not used to mislead. Commercial copying, hiring and lending is prohibited without express permission.”

Is it good? The answer: Part maybe, mostly FAIL

So, there actually is an original source, which gets absolutely no attribution or credit in any of the pieces currently making the rounds. While I was eventually able to verify the validity of the core of the information provided, my efforts to do so raised many worrisome concerns about the original versions of the article which are being shared, concerns about ethics, legality, accuracy, and intent. So. Sigh.

Before I leave this, I want to point readers to the CRAAP test, which highlights five key elements to consider in evaluating information quality: Currency, Relevance, Authority, Accuracy, and Purpose. For this effort, I didn’t really consider currency, since all versions of the information are within the past few months. Ditto relevance. Where this became concerning was when looking at authority, accuracy, and purpose. StudyFinds took a press release about a research study that just begun, with the release focusing on that they now have the funding to do the study, and StudyFinds rewrote it to sound as if the study is almost done and the test will be available soon (ie. inserting inaccuracies and misleading information). They did so as clickbait to generate advertising revenue for themselves, while obscuring any link to the original information source. I call this a FAIL. The original information from the NHS and U. Cambridge was good, although not as exciting as StudyFinds makes it sound, but what came out of StudyFinds is nothing but clickbait.

Pacemakers, Defibrillators, & (Almost) Everything Apple

An iPhone peeking out of the left pocket of a blue & brown floral Hawaiian shirt.

This is to boost awareness of Apple’s release a couple days ago of their list of devices (a long list!) that might interact in not-so-great ways with pacemakers and defibrillators and other implanted medical devices.

Apple: About potential magnetic interference with medical devices

This isn’t a new idea or a new problem (risks of cellular phones to pacemaker patients was mentioned as early as 1995!), but the technology in phones has gradually changed to become safer in many ways, and the technology in pacemakers has also been changing. Early on, the problems were more related to frequency and power, but those problems were largely sorted out by 2010. Experts spent a lot of time over several years working to convince people to not be too scared of their phones or other devices. Harvard, in 2015, reminded folk that the risk is small, and can mostly be avoided by never carrying your phone in your shirt pocket and answering your phone on the opposite ear from your pacemaker.

Now, the concern is about magnets in the devices.

US: FDA: Magnets in Cell Phones and Smart Watches May Affect Pacemakers and Other Implanted Medical Devices

This was followed up by a report in JAMA, on June 15th.

Voelker R. Do Magnets in Consumer Electronics Disable Implanted Medical Devices? JAMA. 2021;325(23):2336. doi:10.1001/jama.2021.8898

The gist of the messages still is to not put your phone in your shirt pocket (or any of the other devices on Apple’s long list, including iPads, chargers, and more). You might want to also think about backpacks, since you want to keep the device a solid 6 inches away from your pacemaker or defibrillator.

(un)Diagnosed: Day 429 (14 Months, 61 weeks) Better, and Better, and …

A grid of four photos shows macros of (clockwise from upper left) a Pedialyte bottle, digital thermometer reading 95.4F, nebulizer tubes, and a pulse-oximeter reading 96% oxygenation with a pulse of 56.
Pedialyte, 95.4F temperature, nebulizer tubes, pulse-ox = 56 pulse, 96 O2.

Here we go again, my now monthly update on life with Long COVID. Things are much better, but still complicated. Last month I mentioned that I have a neurologist now among my specialists, and that he’s made some suggestions that really helped. The most obviously impactful suggestions are increasing electrolytes, wearing an abdominal binder (not pretty, but hey, I’ll take it), and increasing my mast cell inhibitor meds (which has drastically improved the quality of my sleep, also helps with brain fog, among reducing other symptoms).

A month ago I had been able to increase my walking. I was up from walking around the block I live on once a week to twice a week. (Before that there were several months where I had been unable to walk around the block.) I tried every other day, but at that time this was still too much. I am now up to being able to walk around the block two days in a row, but I still have to rest the third day. This is simultaneously exhilarating and disheartening.

What happens on that third day if I try to do the walk? Well, the first day, walking around the block is just lovely. It’s amazing how, when you haven’t been able to, getting to the other side of the block can look like you’re on vacation. Here’s neighbors, flowering bushes, birds are singing, all these things I’ve missed for so long without necessarily realizing I missed them. The second day feels empowering. Look at me, it feels just the same, sauntering along, I can do this, I’m back to normal, soon I’ll be able to do everything. Right. The third day feels just the same as the second for the first hundred yards or so. Then the fog starts to kick in, I’ll start to have some balance issues, wobbling just a bit. After another hundred yards I’m aware I really need a rest. Luckily my block has a place to rest there. Halfway done, now to get back home. I lurch back to my feet, and the rest of the walk will be staggering as if I’m drunk, balance just gone, struggling to keep my head up and my eyes open, arms stretched out to improve proprioception, trying not to accidentally run into people or walls. So, I’ll try two days on and one day off for another couple weeks, and then three days, and keep nibbling away at it.

I am improving with ADLs (activities of daily living). I can make my own meals most of the time. I can do my own laundry. I can help with dishes sometimes. I am FINALLY able to do a little bit of housecleaning sometimes. Let me tell you, after a year of being largely bedridden outside of work hours, the house is pretty terrifying. I mean, REALLY terrifying. I honestly didn’t see how bad it was until the brain fog lifted more consistently, and I hadn’t realized how bad and constant the brain fog was until it started to go away.

Brain fog ebbing gives me more spoons for cognitive work. This means, yes, I’m able to do a higher level of work, more creative work, but it also means that I am able to do things like remember I made a promise to someone and followup on it, able to plan my time to reserve energy for specific things, better able to predict my crashes, and better able to notice my body’s warning signs of needing rest. It also means that I am more prone to thinking I can do all the things I used to do, and find myself locked in hyperfocus working too many hours trying to just finish that one last thing. I’m finding that I need to take a fairly significant break midday and step away from work to do something completely different. Unfortunately for my body (and fortunately for almost everything else), part of doing a job is being part of a community of people engaged in related and interwoven activities toward common goals, and when my body announces it would like a break, thank you very much, this doesn’t always align with everyone else’s schedules. When I push through to accommodate large group meetings or meetings that had been really challenging to get scheduled, I find those days I’m back to spending the evening flat and foggy.

The other important thing for me that is connected to a reduction in brain fog is my ability to read is coming back. I can now read research articles and make sense of them. I can read challenging books on serious topics if I break them up into small bits and stretch it out. I’m still reading mostly light fluffy fiction, but I’m able to read more at a time, read longer, read faster, and even if I’m not yet able to read my usual materials on a regular basis, I count it a win that I’m able to read them at all. I’m counting on my mental muscles stretching just like my energy envelope is growing.

The toughest part of improved and more consistent cognitive function is that I realize better just how bad I have been, and how far I have to go. This is scary and sad. I didn’t feel as scared about it before, I think because I simply lacked the energy to project into the future likely impacts or realistic outcomes if my symptoms persisted. I’ve been kind of Pollyanna-ish about all of this. Not a bad approach, and it’s paying off, but I’m having more days where it’s all rather overwhelming.

There are some other things that have improved as well! I’m not as cold all the time (although my temp was 95.8 earlier today). I still cover up with blankets most days, but not ALL day. I wear layers of winter hats, but less often. People who haven’t seen my hair in four or five months are surprised by my haircut, which happened in December, but I’ve been wearing layers of hats all the time for months. My hands still tremble, but it’s minor and less frequent, and I can work through it, often without really noticing (my son is the one who notices). My ability to taste and smell is much better. Instead of about 5% with erratic blips of partial or full flavor, I’m at more about 70%. I can taste and smell pretty much everything at a less sensitive level than I used to. I can actually sing more often than not, and my voice doesn’t often make the machine gun noises it used to always do when I tried. My vocal range had decreased from 3.5 octaves to 0.5 octaves, and is now up to about 1.5 octaves. This is enough to sing in choir again. Many people with Long COVID have had hair fall out by the handfuls, while I just had a lot of hair turn gray or white. I already had a gray streak in front, which turned bone white at the peak of the illness, and a lot of the hair around it turned gray, hair on the sides and back of my head as well. Well, now, some of my hair color is coming back, and the patches of gray are shrinking and the white is going back to gray. I don’t expect to have it all come back, but this is heartening and tells me I am genuinely getting better.

Staying Safe on COVID Vaccination Sites

CDC: Vaccine Finder: https://vaccinefinder.org/

The main thing nagging at my brain after my previous post about COVID vaccines (“Looking at … COVID Vaccine Black Markets & the Role of Tech“) has been the idea that some of the sites for finding vaccines are phishing sites that harvest personal information for identity theft. I had thought that mentioning this in the original post, and including a link to the CDC’s Vaccine Finder website would be sufficient for me to mention. I’ve gotten some feedback to the effect that, no, people simply do not want to believe that this is an issue, and no we don’t need to talk about it. As a librarian, a big part of what we do (and what I do) day in and day out is related to assessing quality of information, and helping folk learn how to do this better themselves. This makes a great example to walk through some of that process. What I hope to do in the rest of this post is break this out in three parts: 1) more explicitly break out why you should be careful on COVID vaccine finder sites; 2) give an example of assessing the safety of a site; and 3) point to just a few examples of good sites for finding COVID vaccine information and appointments.

Are COVID Vaccine Sites Risky?

For me, I’ve seen enough online misinformation that I just tend to err on the side of assuming sites I don’t already know and trust can’t be trusted until proven safe. That’s kind of my general approach to looking for information online. For myself and my family, we get vaccines, and there is a big difference between being worried about COVID vaccines themselves and being worried about the websites where people go to find appointments for their vaccines. While I want other people to also get vaccines, I don’t want people to have anything bad happen while they are trying to get their vaccine. Here are some of the warning messages about the potential risks of COVID vaccine sites that made me think I wanted to be careful while making my appointment.

Telling the Good Sites from the Maybes

This doesn’t apply just to COVID Vaccine information and appointment sites, but are basic skills to apply to anything you look at online or offline. As Mark Twain so famously said, “Be careful about reading health books. You may die of a misprint.” There are dozens of tools to help people remember how to assess information quality. One of the most famous and popular (and memorable) ones is CRAAP (2010), from Sarah Blakeslee and friends at CSU-Chico.

  • C = Currency
  • R = Relevance
  • A = Authority
  • A = Accuracy
  • P = Purpose

This is short and sweet, unlike the one I came up with many years ago: CHAIN of TRUST (2006), when I tried to simplify the really, REALLY complicated one in my book (1998-2004).

  • C = Candor
  • H = Honesty
  • A = Accountability
  • I = Information Quality
  • N = Neighborly
  • of
  • T = Timeliness
  • R = Relevant
  • U = Unbiased
  • S = Scope
  • T = Trustworthy

You might get the idea that librarians have been working on this a long time. I certainly wasn’t the first, and learned a lot about assessing information quality from tools developed for print materials before the Internet even existed.

So let’s take a look at a vaccine finding site with these ideas and principles in mind. This is not a tutorial applying either of these tools (many of those exist), because this is going to be even shorter. This is where I start these days when I’m trying to decide if I trust a website: Who, Why, What, Where, When, How. Those probably look familiar, since many of us learned this set of questions in a school lesson on journalism or storytelling, and a good website should do a good job about telling their own story. But usually I can weed a site out or decide I’m suspicious about them with just the first three.

  • WHO made the site, and is it easy to figure out.
  • WHY did they make the site, and are they up front and honest about their goals.
  • WHAT does the site actually provide, is it provided legally, is it what I want, and is it provided in the way I want it.

The COVID Vaccine finding tool that I’ve been recommending the most is the one from the CDC (Centers for Disease Control and Prevention): VaccineFinder.org. A screenshot of the top of their main page is at the head of this blogpost.

Screenshot of text: "We want to make vaccination easy and accessible to everyone.
VaccineFinder is a free service where users can search for locations that offer vaccinations. We work with partners such as clinics, pharmacies and health departments to provide accurate and up-to-date information about vaccination services. VaccineFinder is operated by epidemiologists and software developers at Boston Children’s Hospital and supported by the Centers for Disease Control and Prevention and the United States Digital Service."

If you scroll down from the main page for Vaccine Finder they do a wonderful job of answering my most important questions. Who are they? They are epidemiologists and software developers from Boston Children’s Hospital working in collaboration with and funded by the CDC. They also partner with “clinics, pharmacies, and health departments to provide accurate and up-to-date information about vaccination services.” Then they have a “Contact Us” button so you can ask more questions, as well as listing other partners such as Harvard and Castlight Health on a logo banner. Given that this is funded and sponsored by our government, and developed and designed by a collaboration of reputable organizations, I would trust this site, as long as it actually does what it says it does, which it does.

Vaccine Finder: Search Results for Ann Arbor area.

What Vaccine Finder shows me when I search for vaccine appointments in my area is a list of all the places that are providing vaccines to the public and whether or not they currently have vaccine in stock. Note that bit about available to the public, because I actually received my vaccine through the clinics for my insurance, and they are not listed because they aren’t open to the public, only to people with that insurance. The site did list 50 different locations from several different pharmacy and grocery chains as well as small businesses with only a single location. The large map for the state appeared on the main page, but after I searched for a specific zipcode it switched to a more detailed map. Note that Vaccine Finder doesn’t require that you be at the location you want, so you could search for vaccines in a different state, perhaps where a friend or loved one lives. It allowed me to customize based on which vaccines I was interested in. It also allowed me to specify how far I want to drive. To make the appointment, I would have to click through to the location’s web site or phone to make an appointment. The Vaccine Finder site does not make the appointment for you. Vaccine Finder does not have an app for mobile devices, but instead designed a site that is mobile friendly and can be used on any kind of smartphone or tablet.

Let’s compare that with another site that is really popular among my friends and relatives, Find-a-Shot.

Screenshot shows Michigan Find-a-Shot page, with map showing dots for location, and a text-based list of locations in Lansing and Jackson.
Find-a-Shot: https://www.findashot.org/appointments/us/MI

Find-a-Shot automatically figures out where you are, and pushes you to the webpage on their site that matches your location. For some people, that makes things easier, for others it makes them worry about privacy issues. It allows you to search for location by zipcode or state as well as it identifying your location. Find-Shot mentioned on their page that some vaccine providers have blocked them from retrieving information about vaccine availability, and that they are negotiating with those companies to try to restore access to the information. They list six pharmacy and grocery chains they are working with for information (CVS, Kroger, Meijer, Rite Aid, Walgreens, Walmart), but no matter what I did in the site I was only able to retrieve vaccine location information from Rite-Aid, unless I clicked directly on the green dots on the map. The map is identical to the one from the Vaccine Finder website, but did not appear to allow the more precise map for a specific location, at least not easily. It didn’t say whether or not they have vaccine available, but whether they have appointments available, and again pushes you to the provider website for scheduling. Find-a-Shot does come right out and say they don’t keep any information on people who use the site, which is a comfort.

“Findashot.org collects no personal information about users of this site. We use Google Analytics to understand aggregate traffic patterns. Your location is only used with your permission to search for locations close to you and to show the distance to listed locations.”

So, there are some significant functional and interface differences between the two sites, but can I answer my two main questions for Find-a-Shot, what and why? Sort of. Find-a-Shot is a crowdsourced site run by volunteers, which means that officially the information comes from people all over, rather than a specific team or organization or individual. That said, it does ask you to buy a coffee for the person behind the coding for the site, who is not named but evidently was in Texas at the time. They have a banner of logos, but instead of the logos showing their organizational partners, it shows news sources that have mentioned them in an article. If you read the articles, some of them mention the person behind the site. They do list Find-a-Shot’s partners in text: GetMyVaccine.org and VaccineSpotter.org. GetMyVaccine is another crowdsourced list of vaccine appointment locations from major pharmacy and grocery chains in different states. It does not provide any information about the people behind it, but if you dig deep enough you can find a tutorial video from Erick Katzenstein. I haven’t watched the video, but it looks like he is probably the person behind the website. Vaccine Spotter doesn’t appear to be crowdsourced, instead listing the companies from which it scrapes the information. Vaccine Spotter does something else nice — they’ve put the code for the site in GitHub and made the project open source. And while they don’t say who they are on the site, they do list a personal Twitter address for Nick Muerdter, which means its a little easier to find a person. So, for all three sites associated with Find-a-Shot, they give the impression of being well intentioned folk, but it is a lot more work to make that decision. I would still say this is a site that is okay to use, it’s just a lot harder to answer those little questions like who is doing this and why are they doing it.

I didn’t go looking for a vaccine finder site that is overtly bad. You know why? Because I’m on a work computer, and I don’t want to risk going to a site that isn’t trustworthy. Some of them do the phishing by asking you to fill in a form or answer questions, but some of them could possibly gather information from your computer without you having to know it’s happening. After all, that’s how Amazon and Facebook know so much about you, and they are (mostly) trying to use their powers for at least hypothetical good (and likely to be at least mostly responsible because they want to keep the government out of their business).

Tips and Resources

You already know my favorite place to start — Vaccine Finder. But there is no one-size fits all website for this.

It’s a lot of work to find a vaccine appointment slot. It’s getting better, but oh, it’s been so awful, and some of the websites are so painful to use. The first time I tried to make a vaccine appointment, I wanted to cry, and I gave up, and waited weeks to a month before trying again. Of course you want to find an easier way to do it, and that’s why all these sites are popping up trying to solve these problems. And that is also what makes this such a wonderful opportunity for the unethical folk. Most of the sites that are doing this are genuinely trying to help people, but not all of them are from nice folk. How did I decide where it was safe for me to make my appointment? This is where we get back to CRAAP and CHAIN-of-TRUST. This is why I ask WHO as the first question when I am looking at a site that is giving or taking my information or money.

  • Government
    • Federal
    • State
    • County
    • City
  • Insurance
  • Clinic or health system
  • Public health department

If a website is from the federal government, I hope they are going to do the right thing. Again, this can be (and often is) debated, but for today, let’s just assume that it is in the best interest of the government to make it as easy as possible for people to get vaccinated so we can get the pandemic more under control. Even if you don’t trust the government perfectly, it’s fair to assume that there is nothing they are likely to find out from you scheduling a vaccine appointment that they don’t already know about you. (In case you haven’t guessed, I’ve been talking with people who are REALLY concerned about some of these issues.)

Next, if you are lucky enough to have insurance or belong to a health system, these are likely to have their own system set up for getting a vaccine, and it is going to be more private than most of those pop-up home grown web sites to help people find their vaccine. It might not be as easy to use, though. State and country health departments are another place to check, and the CDC has a list of them all for the USA, if you aren’t sure how to find yours.

Knowing the sites to trust isn’t enough, though, if they are too hard to figure out. There are a number of places with people volunteering to help other folk walk through the vaccine process. Local churches and non-profits are not bad places to start, or community organizations, especially if you already have a relationship with them. There are people using the appearance of being a volunteer to do other kinds of scams, so you really want to start with someone you already know and trust, if at all possible. Try asking at the local public library reference desk, if that’s an option. There are some vaccine volunteer organizations that are being recommended by trustworthy organization, if you need help and can’t find it any other way. Here are a couple links for more information, just in case.

(un)Diagnosed: Day 398, Week 57, Month 13: Making Progress

This month actually still looks a lot like last month, still very much good days and bad days, although some significant things have happened. The good days are better, and the bad days aren’t as bad as they once were. I have a new specialist, a neurologist. They say, oh, yeah, I DEFINITELY have dysautonomia! They added POTS. This gives me what has been appearing as an unholy trinity of diagnoses that have been cropping up among many of my friends and social media acquaintances: joint hypermobility (like EDS); mast cell issues (autoimmune and MCAS especially); and POTS (or other forms of dysautonomia). Yay, I joined the club? Or not so yay.

The neurologist had a list of things people can try to feel better, and which patients sometimes discover on their own. I was doing most of them already (examples: salt loading, increased fluids, sleeping with a raised head of the bed, taking breaks where I elevate my legs, neuro rehab, compression stockings, and more). It seemed to surprise them that I was already doing so many. Since I wasn’t doing everything, we’re adding the rest and doubling down on interventions which are low cost, low risk, and offer a big bang for the buck. Compression stockings are shifting from knee high to thigh high. Adding an abdominal binder, which you can think of as a medicalized corset. Even more salt (a LOT of salt!). And fluids. Specifically electrolytes. I’m up from a half gallon a day to a gallon, at least half of which is oral rehydration fluids (like Pedialyte, although I’m using TriOral). It’s amazing. It has really cleared out a lot of the brain fog. I have a fair amount of experience powering through brain fog because of having celiac, and I’m also pretty good at ‘faking’ feeling okay when I’m not. The idea that the tunnel vision feeling I have been living with will just vanish if I drink a pint of electrolytes? MAGICAL!

An example good day: With the brain fog cleared out, I could successfully do many of the things I’ve been struggling with. I could also better manage actually taking breaks appropriately instead of slipping into brain fog and hyper focus. I’m also getting better at recognizing when the brain fog is starting, and taking action to head it off, like electrolytes and raising my legs. Last Saturday was the best day I’ve had since before the pandemic started. I have for many years tried to follow the National Poetry Writing Month practice of writing a poem a day during April. Last year didn’t go so well, but trying again this year. Here’s an excerpt from the happy sonnet I wrote for last Saturday in my poetry blog.

“A day almost like beforetime, when I
could walk if I wanted and still breathe, twirl
as if music is lilting or play twister
and not fall. The luxury of an airway
uncluttered, muscles not withered, and hey…”

PF Anderson, Singing, #NaPoWriMo 2021 Day 10.

There are still bad days, too, and they seem to be triggered by a combination of things. We know that maintaining personal hygiene still seems to trigger crashes. Doing too much does also. Not taking breaks. Etc. Last week the inaugural COSMO conference happened, and I was on the planning team, so, yeah, I did too much and didn’t rest enough. I also had lab tests for the neurologist and to test whether the vaccines actually triggered antibody production, since having COVID didn’t. Crashes for me come in waves — there are immediate crashes during activity, delayed crashes at 18-24 hours after activity, and even more delayed crashes at 3 days out. I read about someone who has crashes at 5 days after their triggering activity, and that must be really hard to manage. So the trip to the blood draw and the extra COSMO activity were 2 and 3 days before the now weekly shampoo, and these three combined to ill effect. The good news is that boosting electrolytes helped reduce the impacts of that crash. Here’s my Facebook post from Sunday describing how that day worked.

"I didn't like seeing my friends. It wore me out. Everything was hard for me: having a conversation, focusing, not being tired. I had to prep before they came over, sleep and store up my strength." Image shows a grayscale pencil sketch of two young women talking while a third stands smiling in the doorway behind them.

Today I read PARENTHESIS by Élodie Durand. It was very strange to read. I don’t have brain cancer, but her description of her life feels so much like mine in some ways.

Yesterday was a good day. Probably the best day I’d had since before COVID19. Today was not a good day. The worst crash I’ve had in a couple months.

I felt fine when I awoke. Started a load of laundry. Took my meds and the first quart of electrolytes. By 9:30am the chills had started, but I hadn’t eaten yet, so kiddo helped me make a bowl of cereal, and I made myself eat it before I lay down.

By 10:30am I was back in bed, covered with the weighted blanket and a few more. By 11am I’d passed out. When I woke at noon I couldn’t talk or lift my arms. I tried, but I didn’t make sense. I couldn’t remember the words I needed. I couldn’t construct a sentence. I couldn’t ask for the help I needed. I would say the same word over and over, frustrated that kiddo couldn’t figure out what I needed. Later, when I could talk again, we agreed that the next time this happens he should record it to we can show the doctors.

A few weeks ago I started to see a new specialist for the post-COVID dysautonomia, a neurologist who has other #LongCovid patients and who specializes in autonomic disorders. He has added POTS to my diagnostic collection. He was surprised & pleased how many of the things they recommend I was already doing. So he bumped things up.

Some of the things he added: 8 grams of salt a day (that’s a lot!). A gallon of fluids, half electrolytes, half water. In a few weeks I have an appointment to fit an abdominal binder, which is kind of a medical corset, and thigh high compression stockings. He says these will all help with suspected pooling of blood in the gut and legs. He said the reason for the brain fog is that blood is actually not getting to the brain.

I’ve been finding the electrolytes are having an amazing impact. Drink a quart, and the weakness just fades, the brain snaps into focus, I feel more like myself. So today, when everything went away, I tried to get kiddo to bring me electrolytes.

Usually I just bottoms-up and guzzle a whole quart. Today I couldn’t lift the bottle. He had to get a small cup, pour some into it, help me with it. After the first cup, I could handle the second cup, with both hands. After the second cup, I could pour my own, and could finish the bottle.

So, that was noon. It was a couple hours before I could sit up without help, or stand up to go to the bathroom (because QUARTS of fluids!). I couldn’t read a book because I couldn’t hold it open.

I finished two quarts (yes, that’s an extra, but I seemed to need it today). And, voilà, I’m back! I could make a simple lunch. I can’t stand long, but I can get up and do short activities. Yesterday I did three loads of laundry, a load of dishes, and walked around the block and felt okay. Today, nah. Let’s not.

But I did get to where I could hold a book again. We use TV dinner trays to hold the pedialyte bottle, a cup, the book. I can prop the book up so it isn’t as tiring to hold. It was an amazing book. A bit gutting to have so much of it resonate so tightly.

And tomorrow, I’ll feel fine. How much you want to wager? Well, fine-ish. Enough to sit at a computer and people will think I look normal.

The NICE Transgender Evidence Report (and How to Read It)

"Enough’s enough. In the last 24 hours 
@hannahsbee
 & I have been called dishonest journalists, unethical, accused of killing children, liars...All for highlighting the lack of good evidence for an intervention used on kids & reporting on whistleblowing concerns at an NHS service" Deb Cohen
https://twitter.com/deb_cohen/status/1378099014340579331

Last week Twitter was blowing up over a new UK evidence review (using systematic review methods) on the topic of puberty blocking or delaying treatments for children and youth who identify as transgender. The largest pushback I witnessed was being directed not at the authors of the evidence review (link will force a PDF download), but the authors of the BBC news report that described the findings.


Now, the BBC news report did a fairly good job of reporting a synopsis of what the NICE review found. Minus one critical piece of context, which I would like to fill in here for people. I am speaking here as someone who previously has had a not insignificant side-gig as a consultant on systematic review methodologies. At the time, there weren’t so many of us medical librarians who were doing this, and now there are a LOT. And most of them will tell you what I’m about to say.

THE FIRST REVIEW ON A NEW QUESTION USUALLY FINDS INSUFFICIENT EVIDENCE. THIS IS NORMAL. I repeat, this is NORMAL!!

This is how it is supposed to work. Someone asks a question, and frankly, someone has to be the first. It starts somewhere. That first review finds insufficient evidence specifically because it is a new question or topic. Often researchers exploring emerging topics haven’t yet agreed on how to study it, how to define the methods and limitations, what are the standards, how to report data, how to define the study population, and so forth and so on. The first review is the first step toward doing this. The first review looks for emerging patterns and trends, picks out those that look most important and most likely to lead to consensus later, and then makes recommendations for future research in this area to use. This is the first really major step toward agreeing on those definitions, standards, measures, methods, etc.

Now comes the hard part. You have to wait FIVE WHOLE YEARS. During that time, people who care passionately will do new research, BETTER research, research that is reported better and meets the new emerging standards and guidelines. After five years, or ten years, now you can redo the study. If the new research on the topic is well done, it will either point to a new finding, or will confirm the original finding. Either way, you will know more. Sometimes it takes 10 years to achieve enough of an evidence base to show that something works. If there is not enough research funding for the topic, it may take longer.

My point is that this is not the end of the question, this is the BEGINNING. It will take a lot of money to fund more research to really answer this question. If people don’t understand how systematic review methods typically work, then politics can kill off the funding, and we will never really know the answer. With a topic as politicized and sensitive as this one, there are chances that policymakers may misread or misinterpret the significance of the findings in this report. That makes it really important to make this very clear.

The only thing this study tells us is that we don’t know the answer YET, according the the criteria specified in this report. If you want to actually know the answer, it is critical to not make a definitive decision, and to keep studying this for a while longer, and in a humane way. It might also be good to look at other reports on this from other authors, and which define the question differently. Consider the role of bias in each. I find it interesting that the similar US report had opposite findings, and am asking myself about the role of cultural context in defining how the questions were approached.

Resources

Evidence for puberty blockers use very low, says NICE https://www.bbc.com/news/health-56601386

NICE, 2021. Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. Download the full report from https://arms.nice.org.uk/resources/hub/1070905/attachment.

Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017 https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a3.htm