There’s an extreme heat warning from the National Weather Service for much of the I-80 corridor today and tomorrow. Heat indices of 95-110+ are expected.
Cooling Centers in Iowa City, IA
Cooling Centers in Coralville, IA
Consider donating to the Iowa City Shelter House Beat the Heat drive!
I want to give a shout out to Dr. George Dawson for his post today “The Autocratic Approach to Homelessness” in reference to President Trump’s most recent executive order, “Ending Crime and Disorder on America’s Streets.” As a retired psychiatrist, I look back and remember seeing the problem of the homeless mentally ill a lot. You can read my take on it from last summer’s posts:
I spend a lot of time joking around on my blog, but this is no joking matter. I think the President gets it wrong.
I just noticed something about one of my YouTube videos that I made sort of as a combination gag and educational piece about pseudobulbar affect. It needed a couple of updates—one of which is minor and which I should have noticed 10 years ago when I made it.
It’s a pseudo-rap performance (badly done, I have to agree although it was fun to make), but it’s one of my most watched productions; it has 18,000 views.
One minor update is about the word “Dex” in the so-called lyrics of this raggedy rap song (see the description by clicking on the Watch on YouTube banner in the lower left-hand corner). It stands for dextromethorphan, one of the ingredients along with quinidine in Nuedexta, the medication for pseudobulbar affect. Dextromethorphan has been known to cause dissociation when it’s abused (for example, in cough syrup).
The most important update is about Dr. Robert G. Robinson, who I joked about in the piece. He passed away December 25, 2024. He was the chair of The University of Iowa Dept. of Psychiatry from 1999-2011. He was a great teacher, mentor, and researcher. He published hundreds of research papers and books on neuropsychiatric diseases like post-stroke depression and pseudobulbar affect. He lectured around the world and was widely regarded as a brilliant leader in his field.
Early in my career in the department, I left twice to try my hand in private practice psychiatry. Both times Dr. Robinson welcomed me back—warmly. He was my co-editor of our book, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry, published in 2010.
All who worked with Dr. Robinson will never forget him.
There’s an extreme heat watch starting tomorrow through Thursday in eastern Iowa. Heat indices of 95 to 105+ are expected.
There is a list available of cooling centers published by KCRG although that was published on June 20, 2025, so it is not current.
Heat safety tips are at this link.
I listened to the Rounding@Iowa podcast “End-of-Life Doulas” twice because I’m at that difficult age when I think about my personal death. I don’t think about it at great length, mind you, but when I think about it, I feel afraid. Early mornings tend to be the time I wonder how much time now until…?
There was the usual podcast format, Dr. Gerry Clancy interviews Mary Kay Kusner, who is certified death doula to get the overview and details about what death doulas are all about.
I listened to the podcast in the late afternoon and discussed it only briefly with Sena. I felt out of sorts for a few hours afterward. I was in a funk until later in the evening when my thoughts almost abruptly switched to something funny. It was about a topic I’m thinking of for another blog post which has a humorous angle to it. I even chuckled a little out loud. I didn’t force that line of thought—it just happened.
But I know why it happened.
I didn’t know what a doula was until I listened to the podcast. Because I’m a writer by inclination, I looked for the original definition, which is a female servant who helps women with birthing. That didn’t enlighten me much, obviously; I can’t remember the last time I was pregnant (see what I did there?). An end of life-or-death doula helps people come to terms with impending death, death when it happens, and with whatever comes up after death has happened.
The title of this post comes from the Mary Kay Kusner’s short anecdote near the end of the podcast. Early in her career as a chaplain, she met with a 4-year-old child in the oncology unit who had a terminal illness, evidently death was coming and asked her, “How will I get to heaven?” They talked about it and the next thing the child said was, “So it’s like another dimension?” which Kusner evidently validated in some way. It’s a really cute story.
Anyway, there was a thread running through the podcast which pointed to what is apparently an ongoing psychological disconnect medical professionals have about death because we’re so focused on cure. It’s disappointing, but there you go. Death doulas are around to fill the role of talking calmly and matter-of-factly about it with patients and families.
There are some nuts and bolts about the profession, some of which I get and others which I scratch my head about. There are a couple of doula organizations in Iowa City which Kusner mentions: Community Death Doulas and Death Collective Eastern Iowa. Mary Kay Kusner is certified as a death doula via online training through INELDA.
Interestingly some people do not believe that this is a profession which can be certified, at least without some practical clinical experience. There’s a web site in which the question-and-answer section is longer than the article itself about this. The author recommends specific courses.
Death doulas are not covered by health insurance, so the practitioners arrange for payment, often through a sliding scale hourly fee. Part of the reason for the training of and demand for death doulas is that hospice nurses have heavy caseloads.
This reminds me of the hospice where my younger brother died after his battle with cancer. He was in his forties. Before he entered hospice, I had to be one of his doctors on the medical psychiatry inpatient unit after he accidentally overdosed on his pain medication.
When my brother was in hospice, I sat at his bedside. Most of the time, he was delirious. I watched and listened as one of the hospice workers as he asked him whether he was entering the dying process. He used those words. My brother was just as delirious as he was when he had to be admitted to the medical-psychiatry unit. I don’t know how much he heard.
I sat at his bedside, determined to hold some kind of death watch vigil. This was interrupted, ironically, by some friends of his who visited. They stood opposite the bed so that I had to look at them instead—and to listen as they told me stories about how close they’d been to him and how much they loved him.
By the time they were finished and I turned back to my brother, he was gone. It took me a little while to figure out I had not missed anything I really needed.
So, I think death doulas could be vital in building a bridge between those who are dying and those who need to connect with them. That’s the main thing.
I read Dr. Ron Pies, MD’s essay today, “What Long COVID Can Teach Psychiatry—and Its Critics.” As usual, he made thought- provoking points about the disease concept in psychiatry. What I also found interesting was the connection he made with Long Covid, a debilitating illness. He cited someone else I know who was involved with a group assigned to create a working definition for it—Dr. E. Wes Ely, an intensive care unit physician at Vanderbilt University in Nashville, Tennessee.
I remember when I first encountered Dr. Ely, way back in 2011 when I was a consulting psychiatrist in the University of Iowa Health Care general hospital. I was blogging back then and mentioned a book he and Valerie Page and written, Delirium in Critical Care. Back then I sometimes read parts of it to trainees because I thought they were amusing:
“…there is a clearly expressed opinion about the role of psychiatrists. It’s in a section titled “Psychiatrists and delirium” in Chapter 9 and begins with the sentence, “Should we, or should we not, call the psychiatrist?” The authors ask the question “Can we replace them with a screening tool, and then use haloperidol freely?” The context for the following remarks is that Chapter 9 is about drug treatment of the symptoms and behaviors commonly associated with delirium.”
I would point out that the authors say, while acknowledging that the opinions of psychiatrists and intensivists might differ, “…we would advocate that a psychiatrist should be consulted for patients already under the care of a psychiatrist or on antipsychotic medications”. Usually, in most medical centers in the U.S.A. a general hospital consultation-liaison psychiatrist sees the delirious inpatient rather than the patient’s outpatient psychiatrist. And many delirious patients don’t have a previous formal history of psychiatric illness and so would not have been seeing an outpatient psychiatrist in the first place.” (Page, V. and E.W. Ely, Delirium in Critical Care: Core Critical Care. Core Critical Care, ed. A. Vuylsteke 2011, New York: Cambridge University Press).
I’m pretty sure I got an email from Wes shortly after I posted that, with his suggestion that I write more about the delirium research he was doing. He sent me several references. I met him in person at a meeting of the American Delirium Society later on and attended an internal medicine grand rounds he presented at UIHC in 2019, “A New Frontier in Critical Care Medicine: Saving the Injured Brain.” He’s also written a great book, “Every Deep-Drawn Breath.”
Anyway, Dr. Ely and others were tasked by the Administration for Strategic Preparedness and Response and the Office of the Assistant Secretary of Health in the Department of Health and Human Services tasked the National Academies of Sciences, Engineering, and Medicine (NASEM) with developing an improved definition for long Covid.
At first, I was puzzled by the creation of criteria that essentially defined Long Covid as a disease state which didn’t even necessitate a positive test for Covid in the history of patients who developed Long Covid. I then read the full essay by Family Medicine physician, Dr. Kirsti Malterud, MD, PhD, “Diagnosis—A Tool for Rational Action? A Critical View from Family Medicine.”
I was hung up on the dichotomy between physical illness and somatization and thought the Long Covid definition posed a dilemma because it purposely omits any need for an “objective” test to verify previous Covid infection, making the Long Covid diagnosis based completely on clinical grounds. The section on persistent oppositions (dichotomies) was helpful, especially the 2nd point on the dichotomy of the question of whether an illness is physical or psychological (p.28).
The point on how to transcend the dichotomy was well made. I guess it’s easy to forget how the body and mind are related when a consultation-liaison psychiatrist is called to evaluate somebody for “somatization.” Often that was the default question before I ever got to see the patient.
Still, the person suffering from Long Covid often doesn’t seem to have a consistently effective treatment and may stay unwell or even disabled for months or years. Social Security criteria for disability look well-established.
I can imagine that many persons with Long Covid might object to have their care transferred to psychiatric services alone. I can see why there are Long Covid clinics in several states. It’s difficult to tell how many and which ones have psychiatrists on staff. The University of Iowa calls its service the Post Covid Clinic and can refer to mental health and neuropsychology services. On the other hand, a recent study of how many Long Covid clinics are available and what they do for people showed it was difficult to ascertain what services they actually offered, concluding:
“We find that services offered at long COVID clinics at top hospitals in the US often include meeting with a team member and referrals to a wide range of specialists. The diversity in long COVID services offered parallels the diversity in long COVID symptoms, suggesting a need for better consensus in developing and delivering treatment.” (Haslam A, Prasad V. Long COVID clinics and services offered by top US hospitals: an empirical analysis of clinical options as of May 2023. BMC Health Serv Res. 2024 May 30;24(1):684. doi: 10.1186/s12913-024-11071-3. PMID: 38816726; PMCID: PMC11138016.)
I’m interested in seeing how and whether the new Long Covid definition will be widely adopted.
Sena has been drinking her prune juice and I presume she’s regular. Besides that, she could be an excellent astronaut. There was a small study by scientists that seemed to show that mice who ate prunes could be protected from space radiation.
I think you’d have to eat a lot of prunes for that. Being regular is one thing, but being less susceptible to the dangers of space travel to places like Mars might mean a serious commitment to prunes beyond human endurance.
It makes me wonder how extraterrestrials tolerate it. We’re always depicting them as humanoid on TV and in movies. Maybe they already know about this. It would give abduction a whole new meaning.
Anyone notice a prune shortage?
The Svengoolie TV show movie next Saturday will be “Invaders from Mars” released in 1953 and it triggered some memories. One of them is when I was a little kid. I think I saw parts of it on TV while I was supposed to be down for a nap. I recall seeing these burly guys in green body suits trotting stiff-legged through tunnels. Their gait is something I can’t forget—no matter how hard I try. For a long time, I thought I had just been dreaming. But I’m pretty sure the nightmare was real because when we saw the movie last year on the Svengoolie show, those Martians looked familiar.
The other memory is of a TV public service announcement (PSA) commercial in the early 1970s. I managed to find a YouTube of it that reminded me of the leader of the Martians. He was in a clear globe and the green guys carried him around. He was just a head with tentacles. He was the leader and was very much ahead of his assistants in an evolutionary sense. At least I think that was the idea. He was basically the brains of the extraterrestrial population. He did all the thinking and planning—but he was stuck in this globe.
Anyway, the commercial is from 1971 and it’s a PSA from the President’s Council on Physical Fitness and Sports. The commercial shows how we’d be by the year 2000 if we didn’t shape up, literally. Richard Nixon was President; during his presidency Apollo 11 landed on the moon—and he resigned from office because of the Watergate scandal. Anyway, food for thought for the upcoming film, “Invaders from Mars,” which probably has a message about leadership.
We watched the Covid-19 vaccine part of today’s meeting this morning. I thought it got off to sort of a rough start, mainly with technical difficulties. I can’t recall any other meetings in which the camera flipped back and forth oddly between speakers and their slides. I thought that was distracting.
The question-and-answer periods ran too long which put them behind schedule. One member of the original 8 committee members, Dr. Michael Ross, was missing from the CDC roster. There were news articles about his withdrawing after a review of financial holdings.
While most of the Covid-19 presentation was review, I thought it was too bad that ACIP Chair Dr. Martin Kulldorff announced there would be no vote on the Covid-19 vaccine today. He also said that the ACIP committee would look forward to the missing Evidence to Recommendations (EtR) material in the fall. Dr. Adam MacNeil, the presenter of the Covid-19 vaccine review, admitted that the EtR was not finished. I was not clear on why.
I didn’t really see the point of Dr. Kulldorff’s giving a rather long speech about why he was fired from Harvard after he refused to get the Covid-19 vaccine. I would much rather have heard him give details about his emphasis on the importance of conducting controlled trials (I think he meant placebo-controlled?) and posing this as a question to Dr. MacNeil. I think this is what led to Dr. MacNeil’s response which implied that they would take too long to produce actionable results (I might be putting words in his mouth but that’s my interpretation)—which could lead to saving more lives. It looked like a rather awkward moment.
Dr. MacNeil reviewed the FDA approval of using a JN.1 lineage vaccine at the VRBPAC meeting in May and also mentioned the FDA leadership preference for the LP.8.1 variant. I noticed the CDC variant genomic tracker today shows that the new kid on the block, NB.1.8.1, is now just as prevalent or more prevalent as LP.8.1. They’re both from the JN.1 lineage.
Some of the questions from the newly appointed committee members were over my head. But in all fairness, one of the members asked a question which not only I didn’t get but that Dr. MacNeil said he didn’t quite understand either.
So far, we’re planning to watch the influenza vaccine presentation tomorrow morning. I’m not sure why there’s a vote on thimerosal in the flu vaccine tomorrow but there was no vote on the Covid-19 vaccine today.
Sena got a measles vaccine booster today just to be on the safe side given the increase in the number of measles cases all over the country, including Iowa.
The history of the measles vaccine is fascinating by the way. It can make it challenging to figure out who might need a booster.
Despite the mild headache from the shot—she won our cribbage match again. She will not be defeated!
Go Retire Psychiatrist 