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The Zika Virus

5

 

Is this going to be a big deal or what? In some areas of the world, it is a big deal, with infants of infected mothers being born with horrible birth defects. But what about the United States? Is it coming here? Let’s see what we know.
The Zika virus is a simple, single-stranded RNA virus transmitted to humans through the bite of an infected mosquito. This is the same species that transmits Yellow fever and Dengue fever, and it can be found in parts of the southern U.S.
We’re not sure what percentage of people will become infected from the bite of an infected mosquito, but only about 20% of those infected will develop symptoms. These include fever, rash, joint and muscle pains, and conjunctivitis. Not very specific, and easily confused with other viral-type infections. The disease is usually mild, and lasts about a week. There’s no treatment, other than supportive measures such as rest, fluids, and OTC pain medications.
The real concern has been the possible association between the Zika virus and a reported increased incidence of babies born with microcephaly (a small brain). Most of these reports have come from Brazil and are still being investigated.
So how do we diagnosis this infection? First, we need to consider where we’ve been. Has there been travel to a tropical or subtropical region in the western hemisphere or parts of Africa and the Pacific islands? If so, where? And how long ago? The incubation period is short—only a week or so. And again, the symptoms may be absent or vague. If there’s been travel to an area of concern followed by the development of fever, rash, and muscle aches, lab testing can be performed to determine the presence of infection. These studies are not routine, and will need to be sent to specialized testing centers, such as the CDC Arbovirus Diagnostic Laboratory. An answer will likely take days to weeks.
What about treatment? At this time, there is no specific antiviral treatment for the Zika virus. The first line of defense is to avoid travel to areas where we know the virus is present, though this seems to be expanding. Then we need to avoid exposure to mosquitos, if possible. Standing water is their preferred breeding area, and it doesn’t take much. Check out your surroundings for anything that’s holding water and dump it. And lastly, be aware of the symptoms of this disease. Again, this is a mild infection and seldom fatal. The risk is for those of us who are pregnant or who become pregnant.
And with that, here are some points to keep in mind:
– There’s no vaccine to prevent this infection.
– There’s currently no specific treatment.
– If you’re pregnant and have travelled in an area where the virus is known to be present, talk with your doctor and get their thoughts.
– Yes, it’s safe to use an insect repellent if you’re pregnant or nursing, as long as it’s approved by the EPA. (Found on the EPA website.)
– Don’t panic. This issue is continuing to evolve and at this moment there are only a few suspected cases in the U.S., localized to Florida. As with anything else, we need to be aware of what’s going on, keep current with well-documented developments, and let knowledge and reason inform our actions and emotions.

High Blood Pressure – FAQs

 

In our clinic, we take care of a lot of people with high blood pressure. And we get a lot of questions.

Once I start blood pressure medicine, will I have to take it for the rest of my life?
The answer here is a straightforward “yes” and “maybe”. Once started on blood pressure medication, most people will need to continue it for the rest of their lives. Keep in mind that the normal aging process brings with it many unwanted changes, including a gradual increase in our blood pressures. And we all know how hard it is to give up bad/unhealthy habits. However, if sufficiently motivated to improve our lifestyles—more exercise, no smoking, achieving and maintaining our ideal weight, really restricting our salt intake—it might be possible to stop our BP medicine. This will need to be carefully coordinated with you physician, but yes, it’s possible. Maybe.

What’s the best time of day to take my medication, morning or night?
I’m glad you asked this question. A lot of people wonder about this, and it turns out to be important. For a long time, we didn’t think it made any difference as to when you took these medicines. The only consistent advice was not to take your fluid pill right before going to bed. Not unless you wanted to get up several times during the night and risk falling over the dog.
We now know that aside from those fluid pills (still good advice to take these in the morning), your other blood pressure medicines should be taken at night, before you go to bed. From a statistical standpoint, more heart attacks and strokes occur in the early morning hours—frequently upon arising—and are thought to be due at least in part to a sudden rise in uncontrolled blood pressure. If your medicine was taken the morning before, it has most likely left your system and left you unprotected. Some of the long-acting drugs have helped here, yet this continues to be our most vulnerable time of day. Take you pills before bed.

The guy at the health food store recommended some stuff for my blood pressure. What do you think?
It all depends on what stuff. There are a few things that might help, but most of the claims by the manufacturers of these supplements are unfounded. They haven’t gone to the trouble and expense to do the necessary research to prove their effectiveness. Or the research might have been done and demonstrated no benefit—maybe even some harm. Yet they continue to be on the shelves of your health food store because no one’s really watching. There’s very little oversight in this important and costly area of our healthcare.
You can find out what you need to know by going to: www.nccam.nih.gov/health/herbsataglance.htm.

My aunt told me to drink a tablespoon of vinegar every night and my blood pressure would be fine. Is she crazy?
You’ll have to answer the last part, but I can tell you about vinegar. There have been many claims regarding the health benefits of regularly consuming apple (white) vinegar. Lowering cholesterol, losing weight, controlling diabetes, and lowering blood pressure. To date, there is no good evidence that supports any of these claims. On the other hand, white vinegar is effective in removing clogs from drains, breaking down glue for easy removal, and helping strip wallpaper. Should you decide to give it a try for medicinal purposes, be aware that it can attack the enamel of your teeth, causing cavities and sensitivity.

I read where Kosher salt is better for you than the regular kind. What do you think?
This is the orthopedic conundrum, only repackaged.
“Mrs. Jones, the x-ray shows little Billy’s wrist is fractured.”
“Thank heavens! At least it’s not broken or cracked.”
It’s all the same. Kosher salt, sea salt, black salt, Himalayan pink salt, Celtic salt, regular table salt—they’re all pretty much equivalent when it comes to their sodium content. There might be some slight variations in contaminants and trace amounts of minerals such as calcium, magnesium, and potassium, but when it comes to your blood pressure and health, there’s not a grain of difference.

I read that ibuprofen is bad for your blood pressure, but naproxen is okay. What do you think?
I think, once again, don’t believe everything you read. You’re right about the ibuprofen. It’s one of our nonsteroidal anti-inflammatory drugs (NSAIDs) and it can raise our blood pressure as well as worsen some of the other cardiovascular risks. But the same is true for all of the NSAIDs, including naproxen. If you have high blood pressure, you’ll need to avoid these drugs. A baby aspirin (81mg) is also an NSAID, but there’s no evidence connecting it with worsening hypertension. And for the record, acetaminophen is not an NSAID, nor does it interfere with the control of our BP.

One of my friends said I’ll have to give up coffee now that I’m on blood pressure medicine. Is that true?
This is tough for me, because I’m an avid coffee drinker—regularly consuming anywhere from 2-6 cups per day. The most current evidence indicates that caffeine can cause an acute rise in blood pressure, but not to excessive levels, and then it normalizes over the next half hour or so. This response is seen less frequently in those of us who are accustomed to drinking coffee or tea. If you regularly drink coffee and your blood pressure is normal, you should be fine. It might be reasonable to conduct a home trial. Check your blood pressure, drink a cup of your favorite brew, then repeat your pressure in fifteen or twenty minutes. If your systolic pressure goes up by more than 10 points, you may be “caffeine sensitive”. If the rise is less than this, you’re probably okay. It would be a good idea to discuss these findings with your physician.
If I get my pressure under control, can I stop taking medicine? And if so, can I stop “cold-turkey?”
Not just yet, and no. As we considered in our first question, it may be possible to stop taking blood pressure medicine if you have achieved your goal and adjusted your lifestyle. You’ll want to be sure you maintain your weight (assuming this has happened), and can continue your other lifestyle changes. Then work with your physician, making sure she advises you along the way. As to how to stop, most medications will need to be tapered—usually over two or three weeks—while your pressure is being carefully monitored. This is especially true for the beta-blockers, since stopping cold-turkey with some of these can precipitate serious problems, including a heart attack or worse.
My nephew is in pre-med, and he told me as long as one of my blood pressure numbers was okay, I’d be fine. You agree with that?
Say what? Where does your nephew go to school? Of course this is not okay. While it’s true there is something called “systolic hypertension”—a condition where our systolic pressure is elevated while our diastolic remains in or near the normal range—this is something that usually occurs as we grow older, is still serious, and it’s something most experts would address. Otherwise, we’re going to target both of our numbers, keeping in mind that elevations in our systolic and diastolic pressures each bring their own set of problems and complications.
I’m about to have a life-insurance physical and don’t want to tell them I take blood pressure medicine. Is there any way they can find out?
Remember what Mark Twain once said:
“If you tell the truth,
you don’t have to remember anything.”
That’s still good advice, aside from the fact that we should always strive to be honest. In this particular case, you’d better be. There are tests that can be done (usually on a urine specimen) to determine the presence of several classes of blood pressure medicines, as well as some of the statins. You’ll find yourself better off by accurately noting your current medications than should you be caught in an intentional deception. Don’t find yourself trapped in that “tangled web”.

The nurse at my doctor’s office says there’s no difference between using a regular size BP cuff or a large one. As you can see, I’ve got big arms. Does it really matter what size the cuff is?
Of course it does. If the cuff is too small, your pressure is going to be over-estimated. And if too large, the reading will be lower than the actual numbers. Remember, the cuff needs to be placed with its lower edge one inch above the elbow, and it should cover 2/3 of the upper arm. Make sure this is done correctly.
Everyone in my family has high blood pressure—going back as many generations as I know about. I’m going to have it, so that’s that, and there’s nothing I can do.
Is there a question here, or just a statement of futility? It’s true that genetics play a significant role in most areas of our lives (nature versus nurture), and our blood pressures are no exception. We are beginning to learn more about this important area and in fact see a trend of hypertension within families and close relatives. While its familial presence should alert you to the possibility of developing high blood pressure, there’s no cause for despair. Rather, this should be viewed as a challenge, something to be managed and overcome. So yes, you can do something about it.

Doc, I read your book about lowering cholesterol. You talk about your faith, and I was wondering how you balance that with being a physician? How do you combine your faith with your science?
I’m glad you asked that question, because it’s the easiest one yet. Francis Bacon (1561-1626) might have said it best.
“Little knowledge of science
makes a man an atheist,
but in-depth study of science
makes him a believer in God.”
The psalmist was right – we are fearfully and wonderfully made.

(Taken from my book “60 Ways to Lower Your Blood Pressure”.)

The HCG Diet

(Are We Really Still Talking About This Stuff?)

It never fails. At least once or twice a week, one of my patients will ask me what I think about these “new” HCG diets. It’s usually someone who has tried everything—except diet and exercise—and has been unable to lose any weight. This is important for them to understand, so I pull up a chair, sit down, and this is what I tell them.

HCG (more correctly notated as hCG and known as the human chorionic gonadotropin) has been known to the scientific community for decades. It’s a hormone produced by the placenta and it has several important functions. In early pregnancy, its’ actions help nurture and sustain the growing embryo and help it implant itself in the uterine wall. The blood level of hCG rises predictably each day of pregnancy, allowing physicians to monitor the healthy progress of a normal pregnancy. And it’s the hormone measured in pregnancy tests, both over-the-counter and in a medical office or hospital. For those of us old enough to be familiar with the term “the rabbit died” as indicating a positive pregnancy test, this same hCG was the culprit. In the 1930’s, researchers determined that if the urine of a pregnant woman (containing high levels of hCG) was injected into a female rabbit, specific changes in the rabbit’s ovaries would indicate the presence of hCG, and the woman would be found to be pregnant. Contrary to popular (and apparently persistent) opinion, the death of the rabbit didn’t indicate a positive test. Rather, it was the changes noted in the ovaries, and the rabbit had to be sacrificed to examine them. We’ve come a long way, and Thumper (or his girlfriend) must be happy.
So that’s hCG—a powerful hormone of pregnancy. But how did this ever become associated with weight loss? This is a good example of bad science gone worse.

Even if you’re not a sports-fan, you’re probably familiar with the continued controversy surrounding “performance-enhancing drugs”. We usually, and rightly, associate this with testosterone-like substances—hormones that promote the growth and strengthening of muscles. There are many problems encountered with these drugs. With prolonged use of these “anabolic steroids”, bothersome side effects can occur, including testicular atrophy. HCG has been found to counter-act some of these effects, and has made its way into this dangerous and illicit activity.

But prior to this, a British physician, Albert T. W. Simeons, developed a diet in the mid-1950’s based on the use of hCG injections and an ultra-low calorie diet of only 500 calories. He claimed significant weight loss with no loss of muscle mass. P.T. Barnum would have known that if you rubbed snake oil on your belly and consumed no more than 500 calories each day, you were going to lose weight, and fast. But that degree of caloric restriction amounts to malnutrition, with its multiple and serious side effects. Scrutiny of Simeons’ diet quickly debunked it, and over the ensuing years, multiple reputable agencies and organizations have attempted to place any hCG diet in its proper place.

Here’s what the FDA had to say in 1976:
“The injection of HCG has not been approved by the Food and Drug Administration as safe and effective in the treatment of obesity or weight control. There is no substantial evidence that HCG increases weight loss beyond that resulting from caloric restriction.”
And in 1995, the “American Society of Bariatric Physicians” took this position:
“There is no scientific evidence that HCG is effective in the treatment of obesity. The studies done to date have found insufficient evidence supporting the claims that HCG is effective in altering fat-distribution, hunger reduction, or in inducing a feeling of well-being. The use of HCG should be regarded as an inappropriate therapy for weight reduction.”
Since that statement, there have been no new studies that would refute this position, nor support the use of hCG. And yet there are “weight-loss clinics” that tout its use and seem to do a brisk business.
And then there’s the Internet. I just went on-line and found the following advertisement of an amazing weight-loss product. Keep in mind that you can lose “1-2 pounds a day” and this is “doctor approved”.
HCG drops are taken orally (Interesting, since hCG is not absorbed through the GI tract)
No injections!
Same results as HCG clinics, but costs thousands of dollars less
No exercise needed while taking them
No prescription required
Our HCG has all-natural ingredients
No hunger pains while taking HCG diet drops
HCG converts fat into nutrients without loss of muscle

All of that sounds wonderful, doesn’t it? And if you read a little further, you’ll find more interesting information in the small print:
“We are in compliance with the FDA guidelines since our formulation doesn’t contain the real HCG hormone, but only its weight reduction qualities.”
Say what? And people actually buy this stuff?

So that’s what I tell my patients. If they buy these products over-the-counter or through the Internet, they’re not getting real hCG. What’s actually in these bottles is anyone’s guess. And if they’re going to an “HCG clinic” and getting the “real stuff”, there are problems associated with these injections. But mainly, it doesn’t work, and you need to question the credentials and motivation of the practitioners in these clinics.
Save your money and stick with a reduced-calorie diet, but not as drastic as 500 calories.

(From the up-coming book “60 Ways to Lose 10 or More Pounds”)

A Christmas Story- December 2015

A Christmas Story 

star

Sometimes, when you least expect it, a gift comes your way.

 

“Well Charlie, your blood pressure is great and your cholesterol is the best it’s ever been. Keep doing what you’re doing, especially with the holidays coming up. Step up your exercise, cut out the salt, and reduce those carbs.”

Charlie chuckled and nodded. He was one of my favorite patients, and a friend.

“I will doc. I know your mantra by heart. Heard it a few times by now.”

He jumped down from the exam table and smoothed the front of his slacks. “And you know mine, too.”

I did know his “mantra”, and I waited for him to share it with me once again.

“Love your Lord, your family, and your friends. Gotta be in that order. Especially at this time of year, with tomorrow bein’ Christmas Eve and all.”

He stood there a moment, studying the tiled floor. “It wasn’t always that way for me, ya know. That wasn’t my focus, my priorities. It took somethin’…It took my almost dying to finally understand things.”

He looked up at me, silent, and I said, “Tell me about it.”

*   *   *

Charlie was twenty years younger when he took off with a couple of friends on a hunting trip to British Columbia. It was the dead of winter, and they had been promised some great moose hunts—maybe even some elk.

This would prove to be a rugged adventure, part of it on horseback through snow-covered forests, and part of it leading their horses up narrow and rocky ravines. On the first night, their guides led them to couple of weather-worn log cabins. Tight quarters, but warm. That wouldn’t be the case for the rest of their trip. They pitched tents in whatever shelter they could find, seeking relief from the near-constant snow and whipping, howling wind.

Worse still—no moose. No sign of any game for three days. Charlie and his friends were wondering if this hunting excursion would prove to be their biggest misadventure, and they voiced their concerns to the lead guide.

Jack was French-Canadian, an experienced hunter and tracker, and a man of few words.

“Soon,” was his response to their complaints.

That was enough, at least for the moment.

But two more days of trudging through drifts as high as their waist was taking its toll. They were tired and frustrated. And cold. The temperature hovered in the minus teens most of the day, worse at night. And they hadn’t seen the sun since getting off their plane in Vancouver. Huddled around their struggling fire, the discussion eventually turned to giving up and heading back down the mountain.

Not Charlie. He hadn’t come a couple of thousand miles for his first moose to give up now. The conversation became more animated, and Charlie was quickly and soundly outvoted. They were going to pack up in the morning and head home.

Charlie turned to Jack. “What do you think? Is there any chance of finding some moose?”

Jack pocked the fire with a long stick then dropped it onto the small blaze.

“Tomorrow.” His words were quiet, muffled by the wind hammering the tent walls.

“What was that?” Charlie asked, leaning closer to the man.

“He said ‘tomorrow’”, one of Charlie’s friends said, shaking his head. “Not me. But if you want to traipse off with him somewhere, have at it. One more day, though, and then we’re out of here.”

“Tomorrow then,” Charlie muttered, his eyes studying the flames as they licked and consumed Jack’s stick.

The next morning, Charlie and Jack were the only ones up at first light. It couldn’t be called “sunrise”, since that hadn’t happened in more than a week. It was just the black of night gradually and grudgingly giving way to what would be another gray and snowy day.

They saddled and loaded their horses, checked their packs for provisions should they get lost, and headed once again up the trail.

For a mile or so they wandered through tall redwoods, the snow not so deep here, and their passage was not difficult. In spite of multiple layers of clothing, Charlie caught himself shivering, and his jaw quivering. He was cold—colder than he could ever remember being.

They emerged from the forest and everything changed. The snow was deeper here—uneven drifts slowing them while a gathering storm threatened more frozen precipitation. Another thirty minutes and they could barely see the narrow trail before them. Jack and Charlie were walking now, leading their hesitant horses up into the fog and snow.

And then he was alone. Jack and his horse disappeared somewhere ahead, leaving Charlie stumbling forward. He called out to the guide, but the wailing wind blew his words back in his face.

His horse knew better, and was balking now, pulling against him. Charlie coaxed the animal, pulling on the reins and leaning into the steep hill. He could barely see the horse’s face when it happened. The wind ceased its relentless blowing and the snow stopped. It was only for an instant, but he had seen it. They were on the middle of a narrow trail—no more than two or three feet across—and on each side the earth dropped precipitously away, falling hundreds of feet to what must be a stony and deadly gorge.

Charlie froze, seized by a fear he had never experienced. The wind picked up and the snow fell harder than before, immediately blinding him. He barely could see the wide-eyed and frightened look on his horse, barely a foot in front of him.

He was going to die, and he knew it.

“Lord, save me.”

Thoughts of his wife and children flooded his mind, and his heart ached in his chest. He would never see them again. So many things unsaid. Some many things undone.

“Lord, save me.”

Charlie had always been a religious man, striving to be good in the eyes of his family and friends. But this was different. His life was about to end, and he sensed a great loss, a great emptiness.

And then the words flowed out of his heart. He understood, and he prayed for forgiveness, for not seeing what was right before him. It wasn’t about himself, or even his family. It was about his relationship with his Lord. That had to be first and foremost.

“Lord save me, and if I make it off this mountain, I will forever tell this story and what you did for me. And I will always try to put you first in my life, and then others.”

He wasn’t bargaining, or pleading. He finally understood.

A peace spread over Charlie, like the warm waters of a tropical beach. He no longer shivered. He was no longer afraid.

“Thank you.”

Whatever happened would happen. His life, as it had always been, was out of his control.

The horse reared, jerking the reins out of Charlie’s hands.

“This is it,” he thought. “We’re both going over the edge.”

The horse bolted past him, someone negotiating the narrow ledge without falling or pushing Charlie to a certain death. He reached out and grabbed the horse’s tail, then struggled to keep up with the animal as it lurched up the hill.

Blinding snow, howling wind, and the certainty of death on either side. Charlie closed his eyes and struggled to keep up.

The horse stopped and Charlie stumbled into its hind-quarters. He opened his eyes and was blinded by the dazzling sunlight of a blue, cloudless sky. Just ahead was Jack, standing beside his horse, looking out over a large, open meadow.

Charlie shielded his eyes, taking in the beauty of this place. He was alive. Somehow, he was alive.

“There.” The guide’s single, solemn word pierced the silence of the meadow.

Charlie looked at him. Jack was pointing to the edge of the meadow where a massive male moose stood near the treeline, its huge antlers moving majestically as he turned his head toward the two men.

“There’s your moose.” Jack held his rifle, ready to back up Charlie should his shot miss.

The moose was looking at Charlie now, his head held high and proud. Their eyes met, and for a moment, there was no sound in the meadow.

Then Charlie spoke. “Nothing will die on this mountain today.”

* *   *

“Wow, I had no idea Charlie. What an experience.”

He took a deep breath and our eyes met.

“I’ve kept my word to the Lord doc. I tell that story whenever I get the chance. I’m not perfect, not by any stretch. But that happened more than twenty years ago and nothing has changed. I know what’s important. That’s my mantra, my song, and I’ll sing it all my days.”

He opened the door and stepped into the hallway.

“Oh, and Merry Christmas.”

Always and All Ways, November 2015

gratitude

Always and All Ways

 

Atticus Sterling was in his early sixties when I first met him. He was in one of our exam rooms at the clinic and told me he needed his blood pressure checked and to be sure he didn’t have diabetes.

“That’s all I need, doc. Doin’ fine otherwise.”

I glanced at his chart and he said, “I know, I know. And before you say anything about my name, I was Atticus before there was an Atticus—you know, ‘To Kill a Mockingbird’—Gregory Peck and all that. I should have asked for namin’ rights or somethin’. Not many of us Atticus’s around.”

That’s how our relationship started. He was quite a character then, and still is today.

Atticus had been in Special Forces and was still trim and lean, and for a man his size, he carried himself with an unexpected fluidity and grace.

He wore the scars of what appeared to be gunshot and knife wounds—badges of violent encounters that he never wanted to talk about.

There was one scar—jagged and raised on the back of his right hand—that he did tell me about one day.

He was stretching his fingers, clenching and unclenching his fist while looking at his hand.

“Got this one in my back yard,” he began. “My wife and I had wanted a dog, so we picked out a rescue pup at a shelter here in town. Sandy, we called him. He’d apparently been mistreated and took a lot of workin’ with, but he became a good dog. Not a mean bone in him. That wasn’t the case with my neighbor. Had we known what he was goin’ to be like, we would never have moved in beside him. He was always lookin’ for some kind of trouble—not direct, mind you. Just always somethin’ sneaky. I should have suspected something… Anyway, Sandy didn’t come in one evenin’ and I went out into the backyard to check on him. I could see him lyin’ near the neighbor’s fence and when I called his name, he just sorta trembled a little. I walked over to him and smelled it right off—antifreeze. You know, that sickly sweet odor. And I knew what had happened. That neighbor of mine had poisoned Sandy. I knelt down beside him and reached out to pick him up when he growled, reared back, and tore into my hand.”

Atticus stopped and slowly traced the scar.

“It was my fault. I shoulda known better. That dog looked up at me and whimpered and in those eyes I could tell he was sayin’ he was sorry. And then he died.”

We sat there for a moment.

“What did you do with your neighbor?” Atticus would have little trouble snapping most men in two like some dried twig, and I could only imagine what he would have done to this man out of anger.

“Well, I had to cool off for a while. But then I prayed for him. And that was one of the hardest things I’ve ever had to do. But I did it. And you know what? After a while, I began to realize he wasn’t changin’ at all. Still as sneaky and mean as ever. But you can’t know a man’s heart. Just your own, and I was changin’. My anger for him was gone, and I got past that.”

I glanced at some of the scars on his chest and arms and wondered if he had gotten past those. My bet would be “yes”.

 

That was twenty years ago. He was in the clinic again today to have his blood pressure checked—perfect at 120/78—and to go over the labs we did a few days ago. His blood sugar continued to be a little elevated, in spite of his medication, and his PSA continued to creep northward. But he didn’t want to do anything about that.

“It’s like you told me years ago, doc. A lot of us men will die with prostate cancer, but not from it. What else ya got there?”

The rest of his labs were fine, his EKG was normal, and his heart and lungs sounded great.

“That all sounds good.” Atticus smiled and cleaned his bifocals on his flannel shirt-sleeve. “Looks like I’ll make it for Thanksgiving next week, down in Charleston with some of my family and my youngest granddaughter. Last summer we were all out on Folly Beach and she and I were takin’ a walk. She looked up at me and said, ‘Papa, I love you always and all ways.’ She’s only seven, but she’s got it figured out.”

I smiled and nodded. She did have it figured out.

His chart was lying open on the counter and I ran my finger down his “Problem List”. The page was nearly full.

Diabetes

Elevated cholesterol

Artificial left knee

Elevated PSA

No hearing left ear (land mine explosion)

Complete rotator cuff tear, left shoulder

3 herniated lumbar discs – 2 cervical

The list went on. Atticus was studying me and put his glasses back on.

He cleared his throat. “Just stuff, isn’t it. What was it C. S. Lewis said? You don’t have a soul. You are a soul. You have a body. I believe he’s right, and I’m grateful that he is. And like my granddaughter would tell you, it’s almost Thanksgiving, and I’m thankful always and in all ways.”