This I Believe, Classical

THIS I BELIEVE, CLASSICAL*

Richard Allen Hart, PhD    6 Dec 1930—(12  Jan  2024)

Who, what, where is God? Our current situation is the result of four stages: the Creation, the single cell, biological evolution, and cultural evolution. It is an ever-changing mix of all four.

Evolution is not continuing as it always has. With short term reserves (glucose and fat, cash and savings, education and research), optimize one action until the environment is exhausted.

Preparing for the future is more important than recreating the past. For the first time in a history of over 4 billion years life is making conscious predictions and is directing evolution.   . 

The potential for life is being found throughout the universe. The basic stuff making up genes is now found to be self-assembling. With a large enough brain mass, consciousness appears.

Brains produce and sort spontaneous ideas. Creative brains ask questions. Questions demand answers: real and imaginary. Love (caring) and charity. God and hope. Friends and enemies. 

The environment allows and limits biological (material) and political (immaterial) cycles. The “educated” can entertain an idea without needing to own it and needing to destroy all others (the natural brute-force animal-level of thinking and acting that life is now surpassing).

What is appropriate changes with time. This applies to English moths and to cultural customs. The dark moths hiding on tree bark became lighter when burning coal was banned in England. 

The 2,000-year-old core teachings of Jesus remain as cultural customs adjust to industrial and political developments. They provide a common need including hope.

Grandma anticipated living with Jesus as she now does. The changes from small country to mega-churches fascinated her. The Cooperative Baptist splitting from the Southern Baptist and back distressed her. Important things are strongly tied to our childhood and our schooling.

Humans act on their beliefs. Each task and level of organization requires its own application of basic rules in three flavors: Guess (immediate), believe (individual), and know (factual). 

Beliefs are polarized toward the past (religions and politics), knowing the facts, toward the future. The “educated” see little conflict in new revelations of the continuing creation. Strongly held beliefs are real to the believer. This is a continuous source of highly resistant conflict.

The history of human nature shows that church and state can be independent or any combination. Their environments may serve different purposes best when separated. Both require well “educated”, active, learners to balance highly trained and skilled participants.

A belief in God and a belief in the United States of America Constitution are both made of the same stuff that is of little consequence until acted upon; made real. Paul placed mankind on a positive path acceptable to a patient God. The Constitution and Bible place us above animals. The time has come to act that way or suffer greatly. 

                                                                      Next

[Several links and comments are still to be added when I am able.]

                                                              *Addendum

Having worked two months on "the best" videos to ground this one page essay in reality I have convinced myself it is an endless task. Each month a new unexpected event occurs that challenges rationalizations based on what is known at the time. Giant viruses, and searching gene data banks that has now uncovered yet another smaller "life" particle, may help understand the origin of life and help engineer a model of a natural living cell. A cold hard engineered cell may be resistant to the mutations that both plaque and make possible the history of life. Humans that live like animals die like animals. Believers may be forgotten but their faith lives on for better or worse in their decedents.

So today, 24 Feb 2024, I am sorting what I have in hand to post on the Internet. I need the comments as I can no longer remember what is in each citation. Out of sight, out of mind. Browse the find column on the right side of videos for a wealth of related insights. 

 

This page is parked on this old web site as I still know how to do this. It is safe from my shaky fingers as I explore a new "nano" world. God in the bio-nano-world is a far more wondrous concept than ever imagined in the past 4,000 years. We can now "see" everything.

I learn as I write and then search for verification. I see other views and related items that hinder, confuse, or even block communication. See Wiktionary.

This page is a condensation of three one-page attempts to explain the world I have lived in the past 93 years. At times it becomes key words that unfold into endless stories when searched after logging into Wikipedia rather than Googling Google Wikipedia.

The nano-world is young and growing. A lot has changed since I last taught clasical genetics 30 years ago: Automated equipment to duplicate and sequence genes. Finding genes shared by every living organism and saved functionally and non-functionally in human chromosomes. Engineering better and even new genes which renews the discussion of god and ethics.

The nano-world is so vast that a singe research or manufacturing area can encompass a dozen disciplines and specialties. This expands the need for new tool makers and new tool users to make new fortunes and new discoveries. 

Evolution with Hypertext

 

I have limited serious attempts to communicate with others to one page. It all started with a two-year leave with the US EPA, Denver, CO, 1978-1980. If a topic goes longer than that you either do not understand what you are doing or you're lying, in research and government work.

 

Several times, in the past dozen years, I have started to write something about the world that I have lived in. Each time my world has expanded by the time I finished the paper. This time a single page can be made as meaningful as a reader wishes when I use hypertext links to automated updates.

 

Controlling Skin Infections

Controlling Skin Infections

Skin infections are related to the times incontinence wear is examined, the hours each garment is used, urine production, hot weather, and preventative skin care. The hot summer of 2018 was a disaster. The summer of 2019 exhibited almost perfect control with Vitamin A&D ointment.

The coronavirus CODE RED order restricted us to our apartment. I realized the Arlo video cam could now record all the times Margaret received services (time chart). The lapse hours between services (hours chart) shows the variability in the hours each garment was used.

The events on Monday, 30 March, are what alerted me to something new was going on after Margaret was accepted into hospice care. Three times that day, I asked when she would be checked. “I will be back in a bit.” [I earned “a bit” equals 1.5 hour]. My impression of this is that new caregivers had the idea that hospice was coming to do that task. 

Given all of the above, I realized we needed to make plans for a predicted warmer than average 2020 summer. Things happen in memory care. We need to be ready to manage them.

The seven observations made on Tuesday, 24 March, average 3.4 hours apart. The five made on Friday, 17 April average 4.8 hours apart. Urine develops a strong odor in about 3 hours and irritates the skin. 

The Molicare products used four years ago when Provision Living opened in 2015 contained curly fibers. These fibers change the pH of urine from skin irritating basic to acidic. 

Only Molicare pull-ups were provided as part of the full-service memory care plan for mobile residents. It took about three per day instead of five to seven. Now the caregivers want only tabbed briefs for changes on the bed.

The three-week series reveals other things. In general, all services are drifting to later in the day. The timing of night services is less variable. This is related to staffing.

Afternoon dryness checks are the most erratic (not charted). This Is also the case for pain medications (that are charted in the eMAR computer system). 

Observant, familiar, trained, and skilled caregivers can provide an optimum memory care performance when provided with the appropriate supervision and supplies. I think we can be ready for another hot summer.  Pain and bowel medications are reducing urine output.

I would judge that outlier situations can be handled when “things happen”. And, that optimum performance this summer is obtainable on most days.   

Blood Pressure Management

My fingers were so puffed up, when I woke up, that I could not make a fist. This happened for two days. I mentioned this at a care plan meeting a couple of months ago.

“You have a doctor’s appointment in a week. Take your blood pressure each day before you go.” So, I did. I also took the monthly Cedarhurst blood pressure and heartbeat measurements.

Cedarhurst Blood Pressure and Heartbeat

The Mayo Clinic reports the Pulse Pressure is a fair indicator of heart health. Any thing over 60 is bad news. Mine, measured by Cedarhurst, my meter, and the doctor’s office in October was 160 – 77 = 83!! But in July it was 60, when I was in my best health for the year 2019 with a near normal blood pressure; working about an hour a day on the Monarch Butterfly Sanctuary. 

The verdict was to add a second blood pressure medication, Lisinopril, 10 mg, and add more physical activity to my wintertime life. [Daily fitness classes have resumed.]

Measuring blood pressure is like counting sparrows under a bird feeder. I used our old Omron BP785 meter. I used a number of ways to make the measurements. Finely, I hit upon a system of measurements that could sort out the small differences during measurement and the huge differences made by stress and anxiety. 

A best fit then, was to start with a five-minute meditation after putting the cuff on my arm and verifying it was placed correctly by hitting Start/Stop and hitting it again when the OK symbol showed. After the five minutes to reduce distraction; hit Start/Stop for the first reading.

My arm rested on a small pillow on our dining room table.  That put it at the right height and made it comfortable for the time to get five readings. As soon as the unit turned off (two minutes), I hit the Start/Stop to get the next reading.

In general, the sets of five readings show a small steady decline for all measurements. The occasional outlier can be attributed to having to reset the cuff. I got better at this as time passed. An outlier can also be produced by unexpected activity in Memory Care One and to trying to use a timer; both can trigger the startle reaction.

Thirteen Day Blood Pressure and Heartbeat

This chart shows that nutrition, exercise and physical therapy, during a 13 day, less stressful environment, can produce marginally normal results without medication. But the diastolic pressure is getting too low for good perfusion of the heart muscles. Day time is about OK.

Six Samples over One Day

Six samples taken on November 8, with a high stress condition (the third monthly bill for therapy still in error by over a $1,000 and the only copy of the bad bills lost somewhere after our move out of the apartment for two weeks and back; along with other factors) show a very different story.

My blood pressure (red) was dangerously high over 180 mm Hg. My skill at taking the readings yielded almost uniform heartbeat counts (grey).

My diastolic pressure (green) fell below normal. It fell too low on November 9 after taking the first Lisinopril the previous evening. It remained there for the next three days. Lisinopril works. It relaxes blood vessels, they enlarge, and blood pressure falls; with little effect on heart rate.  

My systolic pressure did not remain low but rebounded about 20 mm Hg. Stress. Without Lisinopril it might have rebounded twice as high.

November 7 and 11 are somewhat comparable. Each has one blood pressure in or near normal. The values are lower for both on the 11^th. The systolic pressure (red) is still a bit high but the diastolic pressure (green) is now too low.

The persistent high pulse pressure (systolic – diastolic) is not good. I have been examined twice over the years for heart attack with no definitive conclusions. I do not recall, or never knew, why this was done.

I am willing now to let the meter do what it is designed to do: sum three samples, one minute apart, each day. We will never know the actual readings, and the highs, and the lows. But, in general, that single average is about all the doctor needs to know to manage blood pressure. It only takes eight minutes (including five for meditation to remove distractions) instead of 15-20 minutes and a spreadsheet chart.

It appears that from now on, this will be a balancing act:

1.     Too high systolic invites ruptured vessels.

2.     Too low diastolic invites poor perfusion of the heart.

3.     Too great a difference between the above two overworks the heart.

4.     Any combination of the three is worse. 

5.     An hour a day physical work is recommended (not including daily fitness classes).

6.     Reduced stress and anxiety are essential. 

  

Brushing Teeth

In a couple of months Margaret and I will have lived here four years. We go to the dentist every six months. This time the dentist reported that Margaret needed better brushing.

Brushing was a normal part of the morning toiletry events, in the past. She also was up with the rest of the residents. She would then sleep at the breakfast table.

She now goes to bed when tired, or before 10 pm, and gets up when she wakes up or by 10 am. 

Residents have the right of refusal of everything (according to my understanding of Missouri rules). This can be used to justify almost anything not being done in practice. It removes liability for not being done.

The dental office we used has two doors. One is too narrow to pass Margaret’s wheelchair. The other placed her beside the dental chair. Becky put on the TV, down in front of Margaret. She was happy with the “Price is Right”.

Becky sat down on the end of the dental chair with toothbrush in hand after finishing with me (no cavities and healthy gums). She talked with Margaret about brushing her teeth, now, without moving her wheelchair.

The environment for tooth brushing has now been set. We are at the dentist. There are no distractions. There is a toothbrush held where she can easily see it.

“Ready to brush.” (As a command, not as a question.) One finger touches Margaret’s lower lip. The brush lands beside it. Becky keeps on talking. Time passes. The lips open a fraction. The brush turns sideways and enters.

This two-handed approach is part of routine dental practice. One for the tool and one for the mirror. It worked.

It then hit me, “Get a video.”  I did, at about halfway through the brushing. It starts when Becky stopped and then easily started again.  

Brushing Margaret’s teeth was one of the eight items that was discussed at a care plan meeting about a week earlier. 

Federal rules include a provision that if the resident refuses, but doing so puts the resident at risk, and the resident is deemed not competent to understand, then proceed with the action. 

F677 

(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) 

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and 

NOTE: In some cases, residents with dementia may resist the manner in which care is being provided, or attempted, which can be misinterpreted as declination of care. In some cases the resident with dementia does not understand what is happening, or may be fearful of unfamiliar staff, or may be anxious or frustrated due to inability to communicate. Facility staff are responsible to attempt to identify the underlying cause of the “refusal/declination” of care. 

If it is determined that the resident’s inability to perform ADLs occurred after admission due to an unavoidable decline, such as the progression of the resident’s disease process, surveyors must still determine that interventions to assist the resident are identified and implemented immediately. 

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

This seems, to me, to be the case now: bleeding gums when brushing and sent home with toothpaste for bleeding gums.

Once again, behavior in memory care can be controlled by carefully creating the environment in which it is most likely to take place. We cannot take Margaret each day to the dentist.

We can create in memory care the needed environment and train caregivers (two handed approach) to successfully brush Margaret’s teeth. A low stress setting. No outside distractions. A commanding positive approach. A timing that lets Margaret respond as desired. Uniform, regular, execution each day (as possible) by familiar caregivers who have the knack of visiting with her (distracting) as all of this is taking place.

[The more I watch the video, I am thinking we may need to brush Margaret’s teeth when she is watching Family Feud in the activity area. To this day she refuses to have the TV on in our apartment??] 

A few days after the care plan meeting a curious thing was reported. Three assisted living residents had a knock on their doors in the morning:

“Have you brushed your teeth?”

“I need to brush your teeth.”

“I came to brush your teeth.”  “I brush them myself. I have false teeth.”

[11:30am Margaret just left using the assisted walker, after her teeth were brushed using the new toothpaste. I suggested doing this while she was on the toilet. It worked. I did not see how the two caregivers did it.]

My blood pressure: 6:55am 206/99 (woke up and started writing), 7:30am 169/94, and 9:30am 154/73 (after a five minute rest, reading the newspaper, as I finish writing this). Now to get it posted with the video. Write and post in one day; it will be a rare event. 

Writing makes me feel better. I can let things go; but I can always know I can get them back from my posts on the Internet. It may have an effect on my blood pressure too. Doing anything about a stressor seems to reduce it (talking, writing, getting it done).

Pain Diagnosis

I am writing this in real time. My memory is now failing me more than ever. I just got back from the drug store with the item I went to get yesterday evening.

The process of getting memory care to function again at Cedarhurst in Columbia is having a marked effect on Margaret. Several discussions in the past 2 days led us to an experiment last night.

I have questioned how Margaret goes to sleep for months. I even took a video for the doctor to review: "Just dreaming."

A few days ago, in response to the Executive Director's question, "How are you doing", Margaret replied, "My back hurts." And that was that, except for the surprise of her speaking.

Her back is stressed by the wheelchair, the daybed, and being left in one position for over two hours.

How do you know if she is in pain? One observation was, if she stops crossing her ankles at night so tight you cannot pull them apart.

[Two caregivers, she is not familiar with, came in to take her to lunch 12:03. How that went needs to be another post.]

So, she was given a pain pill early enough to have effect before she was put to bed. Five minutes later the usual facial moves occurred. Another 10 minutes and they stopped!

[2:01 pm after our weekly Sunday visit with my youngest brother and Margaret's youngest sister in Indiana.]

I tried to lift her top leg, "Ouch".  I tried about 5 minutes later with success. A few minutes later the ankles were crossed again.

This morning I again uncrossed her ankles. They remained uncrossed until I left for breakfast,  cleaned the caterpillar rearing boxes, and put magic tape handles on the new monarch crystalids.

"Dr. Hart, Margaret is still in bed at 11:30. She does not want to get up. I informed her of our pain management experiment.

When Margaret woke up, she had bright eyes and a soft smile. She was ready for her morning kiss.

If two pain pills made this difference over night, then she must be in pain otherwise. We will repeat this again tonight. We must then find the source of the pain rather than continue with pain pills.

Is crossing the ankles a body language sign of pain? Is it related to holding the arms very tightly to the body? When this position is relaxed by massaging the thumb, Margaret immediately continues feeding herself with her left hand as if nothing had happened.

I will continue to search with, "Why do alzheimer's patients cross their ankles (legs) at night? I have yet to find such an article. Everyone knows that crossing legs is bad. Setting on a plane over two hours is horrible but not in poorly performed memory care.

I need confirmation that pain is shown by crossing ankles at night; a practice by the patient to relieve pain in the back.

10 July 2019

It is 1:46 pm. Lunch is over and cleared away. I have finished reading the Wall Street Journal left to me by the daughter of a resident who passed last week. Several months ago he gave me his sudoku book as he could no longer work the puzzles. I brought him his paper each day. She brought us milkweed leaves last summer. I am no longer playing the role of an outsider accompanying a memory care resident.

My last doctor visit to discuss Margaret's medications for 30 minutes turned into 90 minutes with both the doctor and the nurse practitioner. They even have a follow up visit scheduled next month. I need to be more assertive rather than observe, comment, and let things happen. Save the Tums.

Margaret is now using half her Xanax pill. The therapy office has become fully staffed by added two more people: physical, occupational, and speech therapy. And best of all, they are people I can work with rather than they working for me or I working for them with little follow up.

An understanding has occurred of what services the residential contract includes (we have no contract with the new owners) and what therapy provides. Cedarhurst now has a full time Quality of Live Coordinator and a full time Director of Memory Care (position open as the person left after a couple of months).

Between the QLC and Therapy, Margaret is thriving. "Now keep in mind. We are not going to cure dementia. We are working to reach her, to unlock her, and to bring out the best she can be."

There is more to performing Memory Care than having the same people often enough that they actually learn how Margaret works; but also the need to train them to perform the same task in the same way consistently. How this is to be done with short-term new hires remains to be worked out. There is a need for a register of unique tasks for each resident in addition to the text book one-size-fits-all performance.

The therapy office has the know how but the end result must be correct practice with the resident in the resident's world. [This brings to mind the experiment in which laboratory instructions were included in the 120-seat lecture hall General Biology presentations rather than in the 24-seat laboratory itself. A total failure. Learning at this level is position dependent. What happens in one setting has little effect 100 feet away in another setting.]

Arlo, the butterfly video clip camera, has captured some task performances that may make good instructional resources. Several care givers have granted me permission to download and edit them into movies. We have discussed how to make an effective instructional movie from the video clips.

Which gets me to the point of this post. There is a dismal lack of communication within the operation with the former owners and the current owner in many aspects. Memory Care and Therapy are now working together to sort out Margaret's needs.

Yesterday the QLC sat down with me and used Margaret's iPad to select software that lets a resident type messages by selecting words to create sentences. I have tried this with no success. I bring a lot of baggage that Margaret does not want to sort through. It makes her unhappy. With a new person she only has the task at hand. This service is part of the Memory Care we have not had for over two years.

And then, as I was eating the noon meal (lunch), I overheard the same comment again, "Surely they would let you use a table knife." This time I stood up and asked, "Could I take a picture?"

[The traditional way of cutting up something in memory care is to use a fork and a spoon, use your teeth, or don't eat it. Also when this location first opened, plates were fully prepared in the kitchen. There was no need for a serving knife.]

This time the meat cut fairly easy.  There was one person setting up the plates. A resident's relative pitched in to help. She found the meat too hot with a shake of her hands.

"Surely there could be a locked cabinet where you could keep restricted useful tools."

Times have changed. The hot table provides servers the means of quickly adjusting serving size for each resident. Residents can have seconds. Now servers need a way to quickly make the servings.

Perhaps this post with actual iPhone 8 video, spontaneous and un-staged, will help resolve the issue.

Draft 3:35 pm. Only once have I written a post in one day.
Posted 6:00 pm. After the evening meal.

Memory Care Monitoring Rules

A Missouri bill has been introduced to regulate resident apartment monitoring by family and/or a designated person. https://www.house.mo.gov/Bill.aspx?bill=HB675&year=2019&code=R

Reviews of online articles are primarily posted by attorneys interested in abuse and neglect. This requires constant recording; storage; and retrieval by court order. A video clip, motion/sound triggered, camera, however, is not a total invasion of a resident’s privacy. This limits its use in litigation. 

There are many positive uses of monitoring cameras that need to be protected from poor legislation: easily sharing the status of the resident, ordering supplies, sharing that smile generated by, "Good morning Miss M____".

I propose the video clip camera be used only as a means of transforming time and place. If you cannot be present, you can still see and hear clips of events at a different time and place.

A video clip camera with two-way voice allows you to be present in real time. This allows caregivers and family to communicate with no additional person being present (you) in a work space that is often small and busy.

The Arlo video clip camera allows you up to seven days to review the video clips. They are then deleted from online storage. They remain in your memory just as if you had been at the scene. Only the time and place you viewed the scene have been changed. 

Apartment Monitor View

After six months of learning to use the Arlo 2 video clip camera, that was purchased to study the monarch butterfly caterpillars, I am of the opinion that it can only provide general information about apartment activities: times caregivers enter and leave, personal interactions (voice and motions) and the type of attention. This proved adequate for skin rash control last year.

The camera does not pick up specific details (bruises, skin rashes and treatments) unless it is within a couple of feet from the target area, with the correct lighting and viewing angle. To find where the monarch caterpillars hid at night will require a careful placement of the camera or a motion tracking camera. 

Apartment Monitor Mount

The camera in Apartment 133 was not a botheration to long term caregivers, who are familiar with my wife and me, as long as it rested on the top of my office desk beside the printer. Mounting it as a room monitor, high up on the wall, changed this.

Our rules have been: 1. I am the only one who reviews the video clips.  2. There is no downloading. 3. Arlo deletes the clips after seven days or I delete them earlier.  

The House Bill 675, 2019, should permit a few simple rules (4) to operate a video clip camera in a Memory Care apartment; that requires no additional work or attention by caregivers then the facility cameras do in public areas (which is none).

1.    Time of use.

The Missouri bill is patterned after Texas and Illinois. They allow unrestricted use of the camera by the family or designated person, without any participation by caregivers being necessary. 

Turning the camera on and off, from within the apartment, creates a break in trust with caregivers. The camera is your presence. It can be better than living in the apartment with the resident, as I have been doing.

 [A continuous camera does need a simple means to block or turn off recording for professional reasons. That person should be recorded, blocking or turning the camera off and again when unblocking or turning the camera on again, and by so doing assumes responsibility for the intervening events and for restoring camera operation.]

2. Restricted Viewing.

Only a family member or a designated person can view the video clips. This same person could be present in the room. However, viewing video clips is different than actually being there. Our culture shuns images of a number of personal and private things and actions. The viewer needs to accept the responsibility of what clip to view and what to skip (“to step outside for a minute or two”).

3. Apartment View.

The camera will be set to a general full apartment view. This captures the spirit of interaction between the resident and caregivers (what memory care is all about).


The camera is a personal, private bond between the viewer, the resident and the caregivers. All three can communicate live with two-way audio turned on and controlled by the family member (“Hello Agnes. Does M___ need more pull ups?

A facility cannot require viewing of any recorded or live apartment video clips. Both states hold a general full apartment view and a facility camera in totally separate categories: one is private and the other public. 

4. Information Usage.

No monitoring video clips are downloaded, stored, or shared in any way. There are no records for a court to request other than your viewing memory. 

Both states allow a facility to request, in an agreement with family and caregivers, to use information from the video clips for training and health purposes.

Where camera alert monitoring of “acceptable” falls (day and night) is not provided by the facility, a video clip motion detection camera can do this at a reasonable cost to the family for fall prone residents. A call to the concierge will beat the two-hour apartment check and get attention when understaffing occurs and/or when in-house communication fails.

MEMORY CARE FACILITY MARKETING 2020

You do not go home and leave Grandma behind locked doors at Blue Bird Haven. A video clip camera is available for each memory care apartment. Training on appropriate use and viewing is free. Yi-Fi camera operation is free.

Be present at any time and from any place whenever it is convenient. You become part of the caregiver team. We do the work. You can help tailor it to her needs.

     Take part and observe the events of the day that take place in your loved one's apartment. Enjoy peace of mind. All clips are deleted after seven days or you delete them sooner.

[Etiquette: Please do not interrupt caregivers when performing a task.  Task interruptions may result in the loss of your camera deposit.]